Fillable PLEASE READ INSTRUCTIONS BEFORE COMPLETING FORM (Pennsylvania)

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PLEASE READ INSTRUCTIONS BEFORE COMPLETING FORM (Pennsylvania)

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PLEASE READ INSTRUCTIONS BEFORE COMPLETING FORM
COMPLETION INSTRUCTIONS - EMPLOYABILITY ASSESSMENT FORM (PA 1663)
An individual with a physical or mental disability which temporarily or permanently precludes him or her from
any gainful employment may be eligible for General Assistance, GA. This form must be completed to document
the disability.
To implement these requirements, we are asking you to complete this form for an applicant for public assistance.
Who may complete assessment: The assessment may be performed only by a licensed physician, physician’s
assistant, certified registered nurse practitioner, or psychologist.
Who signs the form: Only the individual who performed the employability assessment may sign the
form. The signature must be original or the form will be invalidated. Signature
or clinic stamps, labels, and other facsimilies are not acceptable.
General form completion requirements: The information on the form and attachments must be complete and legible.
The inability of county staff to read your material will result in the client’s
application being delayed and the form being returned to you for clarification.
If possible, the form and any attachments should be typed.
If all questions are not answered fully, the client’s application will be delayed
and the form returned to you for completion.
EMPLOYABILITY SECTION
Permanently Disabled: Check this block if the client should be considered permanently disabled
and, therefore, unable to work. When making this determination, you must
consider whether the client is unable to engage in any gainful employment
by reason of any medically determinable physical or mental impairments. A
medically determinable physical or mental impairment is an impairment that
results from anatomical, physiological, or psychological abnormalities which
can be shown by medically acceptable clinical and laboratory diagnostic
techniques. A physical or mental impairment must be established by medical
evidence consisting of signs, symptoms, and laboratory findings, not only by
the individual’s statement of symptoms.
Temporarily Disabled: There are two blocks for use in evaluating a client who is
temporarily disabled - one for a client whose disability is
expected to last 12 months or more, and one for a client whose
disability is expected to last less than 12 months. Check the
appropriate block if the client has an injury or condition that
temporarily prevents the client from working in any gainful
employment. Once the injury or ailment is resolved, the client
can work. The date shown is when the temporary disability is
expected to end. A client whose disability is expected to last
12 or more months may be a candidate for Social Security
Disability or SSI benefits.
Employable: Check this block if, based on your examination, it is not
appropriate to check either the Permanently or Temporarily
Disabled blocks.
EXAMINATION RESULTS SECTION
This section must be fully completed so that it clearly establishes the basis for your decision that the
client is either temporarily or permanently disabled. Simply providing a diagnosis is not sufficient. You
must provide information about the basis for your diagnosis and assessment. Further, documentation
sufficient to support your decision, for example medical records, X-rays, and lab reports, must be
available for further review if required.
Questions: Contact your local county assistance office
PA 1663 (SG) 8/18
CAO NAME AND ADDRESS
CO
CASE IDENTIFICATION
RECORD NUMBER CAT CSLD DIST
RECORD NAME DATE
PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES
EMPLOYABILITY ASSESSMENT FORM
WORKER:
SECTION I (Must be completed by applicant/recipient for public assistance)
PLEASE REVIEW ANY INFORMATION PRINTED BELOW. IF THIS INFORMATION IS INCORRECT, PLEASE STRIKE IT OUT AND WRITE
IN THE CORRECT INFORMATION. PLEASE PRINT OR WRITE CLEARLY. BE SURE TO SIGN YOUR NAME AND DATE THIS FORM IN THE
APPROPRIATE SPACE BELOW.
NAME: BIRTHDATE: SOCIAL SECURITY NO.:
ADDRESS: TELEPHONE NUMBER:
CITY: STATE: ZIP CODE:
BRIEFLY EXPLAIN WHY YOU BELIEVE YOU CANNOT WORK:
I HEREBY AUTHORIZE ALL MEDICAL PROVIDERS TO RELEASE ANY MEDICAL INFORMATION
THAT IS RELATED TO MY EMPLOYABILITY TO THE PENNSYLVANIA DEPARTMENT OF HUMAN
SERVICES. THE INFORMATION OBTAINED WILL BE USED ONLY FOR PURPOSES RELATED TO
AN ASSESSMENT OF MY ABILITY TO WORK AND MY ELIGIBILITY FOR PUBLIC ASSISTANCE.
X
(SIGNATURE) PUBLIC ASSISTANCE APPLICANT/RECIPIENT PRINT NAME DATE
AFTER YOU HAVE COMPLETED THIS SECTION, ARRANGE FOR AN APPOINTMENT WITH
A LICENSED PHYSICIAN (MEDICAL DOCTOR OR DOCTOR OF OSTEOPATHY), PHYSICIAN’S
ASSISTANT, CERTIFIED REGISTERED NURSE PRACTITIONER, OR PSYCHOLOGIST. GENERAL
ASSISTANCE BENEFITS CANNOT BE AUTHORIZED FOR YOU UNTIL THE FULLY-COMPLETED
FORM IS RETURNED TO THE COUNTY ASSISTANCE OFFICE WORKER.
RETURN TO:
PA 1663 (SG) 8/18
RESET
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SECTION II (To be completed by a licensed physician, physician’s assistant, certified registered nurse practitioner, or psychologist)
The information on this form will be used by Department of Human Services, DHS, to make an assessment of
your patient’s qualification for GA benefits based on his or her inability to work. Please complete this section
based on your evaluation of the patient’s statement in Section I, your examination of the patient, and your use
of other medical procedures.
EMPLOYABILITY (Check only one)
PERMANENTLY DISABLED - Has a physical or mental disability which permanently
precludes any gainful employment. The patient is a candidate for Social Security Disability or
SSI.
1.
¨
TEMPORARILY DISABLED - 12 MONTHS OR MORE - Is currently disabled due to a temporary
condition as a result of an injury or an acute condition and the disability temporarily
precludes any gainful employment.
The temporary disability began and is expected to last until .
The patient may be a candidate for Social Security Disability or SSI benefits.
2.
¨
DATE DATE
TEMPORARILY DISABLED - LESS THAN 12 MONTHS - Is currently disabled due to
a temporary condition as a result of an injury or an acute condition and the disability
temporarily precludes any gainful employment.
The temporary disability began and is expected to last until .
3.
¨
DATE DATE
EMPLOYABLE - The patient’s physical and/or mental condition is such that he or she can
work.
4.
¨
EXAMINATION RESULTS: (Both parts of this section must be completed if #1, #2 or #3
above is checked. If not completed, the client will be ineligible for GA.)
DIAGNOSIS (Primary and Secondary):
PRIMARY:
SECONDARY:
ASSESSMENT BASED UPON: (Check all that apply)
1.
2.
¨
¨
¨
A. PHYSICAL EXAMINATION
B. REVIEW OF MEDICAL RECORDS
C. CLINICAL HISTORY
¨
¨
D. APPROPRIATE TESTS AND DIAGNOSTIC PROCEDURES
E. OTHER (Specify) ___________________________________
______________________________________________________
AS A LICENSED MEDICAL PROVIDER, I CERTIFY THAT I HAVE READ AND COMPLIED WITH THE ATTACHED INSTRUCTIONS AND
THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY PROFESSIONAL KNOWLEDGE. I FURTHER CERTIFY THAT
MY DIAGNOSIS AND ASSESSMENT ARE BASED SOLELY ON THE PATIENT’S CONDITION AS DETERMINED BY MY EXAMINATION.
I UNDERSTAND AND AGREE THAT MY DIAGNOSIS AND SUPPORTING DOCUMENTATION MAY BE SUBJECT TO REVIEW BY THE
DEPARTMENT OF HUMAN SERVICES.
MEDICAL PROVIDER (PRINT NAME): TELEPHONE NO.:
ADDRESS:
SIGNATURE MEDICAL ASSISTANCE PROVIDER NO. DATE
PA 1663 (SG) 8/18
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PLEASE READ INSTRUCTIONS BEFORE COMPLETING FORM (Pennsylvania)

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Completed 27 June 2022

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