Application for Benefits - The Department of Human Services

Application for Benefits Provider Instructions: Before completing this Application , access the Income Eligibility Verification System (IEVS) using the client s date of birth and Social Security number to determine if the client is already receiving Benefits . If they are not receiving Benefits , the Department encourages medical facilities to take applications so that the facility will not bear expenses for medical care for which public funds are available. Delays in applications can mean delays in payments for medical Services or total denial of payment. The following forms are needed to apply for medical assistance: PA 600 - Application for Benefits , including the Provider Addendum MA 314 - Eligibility Determination Form (for inpatient care only) If the PA 600 (including the Provider Addendum, when needed) contains the necessary information and verification, the county assistance office (CAO) can determine eligibility for Medical Assistance (MA) and authorize either partial or full payment for medical Services .

application form for health care coverage on behalf of the applicant. The applicant should, if at all possible, complete and sign the form. If someone else completes and signs the form, the application

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