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Pennsylvania Medical Assistance Program Specialty Medication Order Form Prescription/Pharmacy Intake Form Fax: 877-231-8302 Phone: 877-220-6194 NEW TO THERAPY PATIENT INFORMATION M Name: THERAPY CONTINUATION
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How to fill out Pennsylvania Medical Assistance program:

01
Gather necessary documents such as proof of income, proof of residency, identification, and social security number.
02
Visit the Pennsylvania Department of Human Services website or contact the county assistance office to obtain the application form.
03
Carefully fill out the application form with accurate and detailed information.
04
Provide all required supporting documents and attach them to the application form.
05
Double-check the completed application form and supporting documents to ensure everything is accurate and complete.
06
Submit the application form and supporting documents either online, by mail, or in person at the county assistance office.
07
Wait for the application to be reviewed and processed by the Pennsylvania Department of Human Services.
08
If additional information is requested, provide the requested documents promptly.
09
Keep track of the application status and follow up if necessary.
10
Once the application is approved, you will receive a notice of eligibility and detailed information about your Pennsylvania Medical Assistance benefits.

Who needs Pennsylvania Medical Assistance program:

01
Low-income individuals and families who cannot afford private health insurance.
02
Pregnant women and children who meet the income and other eligibility criteria.
03
Individuals with disabilities who require medical assistance.
04
Seniors who meet the eligibility criteria for long-term care services.
05
Individuals who require nursing home care or home and community-based services.
06
Individuals who need coverage for specific medical conditions or treatments.
07
Former foster care youth who are transitioning to adulthood and need healthcare coverage.
08
Individuals who qualify for the Breast and Cervical Cancer Prevention and Treatment program.
09
Individuals who require mental health or substance abuse treatment services.
10
Individuals in need of emergency medical services or access to prescription medications but cannot afford them.
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The Pennsylvania Medical Assistance Program is a state and federally funded program that provides health coverage to eligible low-income individuals and families.
Individuals and families who meet the income and eligibility requirements set by the program are required to file for Pennsylvania Medical Assistance.
To fill out the Pennsylvania Medical Assistance program, individuals can apply online through the COMPASS website, by mail, in person, or over the phone.
The purpose of the Pennsylvania Medical Assistance Program is to provide access to healthcare services for those who cannot afford it on their own.
Applicants must report their income, household size, assets, and other relevant information to determine their eligibility for the program.
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