The PA 635 form, originating from the Commonwealth of Pennsylvania Department of Public Welfare, serves as a Medical Assessment Form crucial for determining an individual's capacity to engage in employment and training activities. It plays a vital role in identifying suitable treatment plans to assist individuals on their path to employment or in assessing eligibility for disability benefits or confirming pregnancy statuses. This document requires completion by a qualified medical provider — including a counselor, social social worker, or mental health therapist, under the endorsement of a physician, psychologist, physician assistant, or certified registered nurse practitioner — and its submission is directed back to the relevant county assistance office.
The Commonwealth of Pennsylvania's Department of Public Welfare has outlined an essential protocol for assessing individuals' capabilities to engage in employment and training programs through the Medical Assessment Form, known as PA 635. This form serves a critical role in determining not only an individual's employability but also elucidates the necessity for, and nature of, potential treatment plans or the possibility of qualifying for disability benefits. For pregnant individuals, it assesses the impact of pregnancy on their ability to work, if any. The completion of this form, which is a shared responsibility between the client and a medical provider—such as a counselor, social worker, psychologist, or nurse practitioner—requires thorough documentation of the client’s medical condition, history, and the proposed steps to either facilitate their participation in work or training environments or support their application for benefits. Furthermore, the form delineates clear guidelines for physicians on confirming pregnancy and explicitly outlines different employability statuses, including employable, limited employability, temporary incapacity, and disability, each with respective criteria for documentation and further action. This article aims to dissect the complexities and nuances of the PA 635 form, shedding light on its pivotal role in bridging health assessments with socioeconomic solutions for Pennsylvanians.
COUNTY ASSISTANCE OFFICE
NAME AND ADDRESS
ReturnToCAOBy:
CAOFax Number:
CASE IDENTIFICATION
CO
RECORD NUMBER
CAT
CSLD
DIST
RECORD NAME
DATE
Commonwealth of Pennsylvania Department of Public Welfare
MEDICALASSESSMENTFORM
This Medical Assessment Form (PA 635) is needed to determine whether an individual is able to participate in employment and training activities, what treatment plan(s) could help the individual move towards employment, or determine if the individual is a good candidate for disability benefits or is pregnant.
COMPLETED BYCOUNTYASSISTANCE OFFICE
Client’s Name
Client’s Date of Birth
Client’s Phone Number
Client’s Address (Street, City, Zip Code)
Instructions to Medical Provider
This form may be completed by a counselor, social worker, or mental health therapist, but must be agreed upon and signed by a physician, psychologist, physician assistant or certified registered nurse practitioner.
Please complete the appropriate section(s) of this form and return (fax or mail) to the county assistance office (above) by
________________.
Confirmation of Pregnancy
If this individual is pregnant, give expected delivery date. _____/_____/_____
Date
NOTE: IF PREGNANCYDOES NOT AFFECT THIS INDIVIDUAL’S ABILITYTO WORK, ONLYCOMPLETE SECTION I OF THIS FORM.
SECTION I MEDICALPROVIDER INFORMATION Please complete this entire section.
Printed Name of Medical Provider: ____________________________________________________
Medical License Number: ___________________________ NPI Number: ____________________
(If Applicable)
Phone Number ( ): ____________________________
Address: ___________________________________
___________________________________
I certify that all of the information provided on this form is true, correct and complete to the best of my professional knowledge. I further certify that, the diagnosis and assessment related to this client’s health condition are based on his/her medical condition as determined by examination and knowledge of this client’s medical history.
I understand and agree that the diagnosis and supporting documentation may be subject to review by the Department of Public Welfare’s Medical Review Team.
Signature of medical provider must be original or the form is invalid. Rubber stamps, labels or other reproductions are not acceptable.
___________________________________________________________
________________________
Prepared by
Signature of Medical Provider
1
PA635 (SG) 7/10
County/Record NumberClient’s NameDate of Birth
SECTION II EMPLOYABILITY
IF CHECKBOX 1 IS SELECTED FOR THIS INDIVIDUAL, DO NOTCOMPLETE SECTION III.
IF EMPLOYABLE, THIS INDIVIDUALWILLHAVE THE REQUIREMENT TO WORK OR PARTICIPATE IN TRAINING FOR ______ HOURS PER
WEEK. PLEASE SELECT ONE OF THE FOLLOWING BASED ON YOUR BEST ESTIMATE OF THE INDIVIDUAL’S CURRENT CAPABILITIES:
1. EMPLOYABLE –
This individual is able to work or participate in training, on a sustained basis, for the hours that are required per week (see above).
with the following reasonable accommodations: ___________________________________________________________________
_____________________________________________________________________________________________________________
2. LIMITED EMPLOYABILITY – Please check all that apply. Please also complete Section III.
This individual is able to work or participate in training, on a sustained basis, for fewer than the hours that are required per week (see above). Approximately how many hours can the individual participate per week? __________________
With the following reasonable accommodations
_________________________________________________________________________________________________________
What is the recommended treatment plan to remediate this condition so this individual is able to work or participate in training, on a sustained basis, for the hours that are required per week (see above) or to increase the hours of participation?
Prescribed Medication
Therapy: ________ hours per week Type: _____________________________________________________________________
Follow-up with specialist: Specialty ______________________________ Name of Physician_______________________________
Referral Made for Patient? __________
Other (describe): ___________________________________________________________________________________________
This individual is expected to be limited from being able to work or participate in training for the number of hours indicated above on a
sustained basis, until ____ / ____ / ______.
3. TEMPORARYINCAPACITY – Please also complete Section III.
This individual’s physical or mental condition precludes him/her from participating in any form of employment or training activity, on a sustained basis, at this time, but the condition is expected to improve within 12 months.
This individual’s temporary incapacity is expected to prevent working or participation in training until ____/____/______.
4. DISABLED – Please also complete Section III.
This individual has a physical or mental condition that is expected to last for 12 months or more, and precludes any form of employment, on a sustained basis, of at least 30 hours per week. The individual is a candidate for Social Security Disability or Supplemental Security Income.
The disability begin date _____/_____/_____.
2
County/Record Number
Date of Birth
SECTION III DIAGNOSIS (ES)
Include name of each Diagnosis with ICD-9 code and description. Please explain how each diagnosis affects the client’s ability to work.
Primary Diagnosis:
Secondary Diagnosis:
Tertiary Diagnosis:
Other Diagnosis:
The individual is following the prescribed treatment plan.
_____ Yes _____ No _____Don’t Know If No, indicate:
Not taking medication as prescribed
Not following up with specialist
Not eligible or appropriate for needed medication or treatment. Explain: ________________
___________________________________________________________________________
Other (describe): _____________________________________________________________
3
After receiving the PA 635 form, it's important to accurately complete it to ensure the individual's needs are properly assessed for employment, training activities, treatment plans, or to determine eligibility for disability benefits or confirm pregnancy status. This step-by-step guide will help ensure that the form is filled out thoroughly and correctly. It's crucial to fill in each required section based on the individual's current medical condition and capabilities as assessed by an authorized medical provider.
Once the PA 635 form is completed and all relevant sections are filled, it should be promptly returned to the County Assistance Office by the specified date. This ensures the individual’s status and needs are reviewed in a timely manner to make determinations regarding their employment capabilities, treatment plans, or eligibility for benefits. Accuracy and completeness of the information provided are essential for the assessment process.
What is the purpose of the PA 635 form?
The PA 635 form, also known as the Medical Assessment Form, is designed to evaluate whether an individual is capable of participating in employment and training activities. Additionally, it plays a crucial role in determining appropriate treatment plans to assist individuals in moving toward employment. For those who may not be able to engage in work due to physical or mental conditions, this form helps to assess their eligibility for disability benefits. The form is also used to confirm pregnancy status and its impact on a person's ability to work.
Who is required to complete the PA 635 form?
The form should be completed by a professional such as a counselor, social worker, or mental health therapist. However, it must be reviewed, agreed upon, and signed by a medical authority - this includes physicians, psychologists, physician assistants, or certified registered nurse practitioners. These healthcare professionals are responsible for ensuring that the diagnosis and assessments provided on the form accurately reflect the individual's medical condition based on examinations and the individual's medical history.
What information is required in Section II of the PA 635 form?
Section II of the form focuses on the individual’s employability status. It requires the medical provider to make a judgment based on their professional assessment of the individual's current capabilities. The medical provider must choose one of the following statuses: Employable, Limited Employability, Temporary Incapacity, or Disabled. Details about the individual’s ability to work or participate in training, need for accommodations, expected duration of any limitations, and recommended treatment plan to improve employability are also required in this section.
How does the PA 635 form address pregnancy?
For individuals who are pregnant, the form includes a specific area to confirm the pregnancy and provide the expected delivery date. Importantly, if the pregnancy does not affect the individual’s ability to work, only Section I of the form, which gathers basic information and medical provider details, needs to be completed. This streamlined approach ensures that only relevant information is provided, simplifying the process for expectant mothers.
What happens if the information provided on the PA 635 form is incorrect or incomplete?
It is imperative for the medical provider to certify that all information provided on the PA 635 form is true, accurate, and complete to the best of their knowledge. Incorrect or incomplete information can lead to delays in the assessment process and may affect the individual’s eligibility for employment and training services or disability benefits. The Department of Public Welfare’s Medical Review Team may review diagnoses and supporting documentation for accuracy and completeness. Authenticity is crucial, as the signature of the medical provider must be original; rubber stamps, labels, or other reproductions are not acceptable.
Filling out the PA 635 form, a Medical Assessment Form required by the Commonwealth of Pennsylvania Department of Public Welfare, demands careful attention to detail. Mistakes in completing this form can lead to delays or errors in assessing an individual's need and eligibility for employment, training activities, or disability benefits. Below are ten common mistakes people make when filling out the PA 635 form:
In conclusion, meticulous attention to each section of the PA 635 form is imperative. Medical providers and individuals submitting this form must ensure all information is accurately represented, comprehensive, and aligned with the instructions to facilitate a smooth and timely review process by the Department of Public Welfare's Medical Review Team.
When dealing with the Medical Assessment Form (PA 635) for the Commonwealth of Pennsylvania, several other forms and documents may often accompany it, especially when assessing an individual's employability or eligibility for benefits. These documents ensure that a comprehensive picture of the individual's health and capabilities is captured. They also help in streamlining the process for the agencies involved, ensuring that all necessary information is available for making informed decisions.
When these documents are used together with the PA 635 form, a holistic view of the individual's situation is developed. This comprehensive approach helps ensure that all factors affecting the person's ability to work or participate in training programs are considered. These documents play critical roles in supporting the individual's journey towards employment, managing their health condition, and in some cases, securing necessary disability benefits. It's all about making sure the person receives the support and resources they need to move forward.
The PA 635 form is structured to assess an individual's capacity for employment, aligning treatment plans, and evaluating eligibility for disability benefits, which bears resemblance to several other documents used within the healthcare and welfare sectors. Two such documents are the Social Security Disability Application and the Vocational Rehabilitation Services Application, each with its unique focus but sharing common objectives with the PA 635 form.
The Social Security Disability Application is designed for individuals seeking financial assistance due to a disability that prohibits employment. This application requires detailed medical information, similar to the PA 635 form, including the diagnosis, treatment plans, and the healthcare provider's insights on the individual's ability to work. However, the primary focus here extends beyond assessing employability; it is also to establish eligibility for financial support from the Social Security Administration. This process involves the applicant's complete medical history, akin to the comprehensive medical assessment required by the PA 635 form, making both crucial in determining an individual's future in terms of employment and financial stability.
Another document with similarities to the PA 635 form is the Vocational Rehabilitation Services Application. This application is used by individuals with disabilities seeking assistance in obtaining employment, enhancing their skills, or adjusting to their work environment. Like the PA 635, it includes sections for medical professionals to detail the individual's capabilities and limitations, as well as recommended treatments or accommodations needed for the individual to participate in the workforce. The key similarity lies in the emphasis on evaluating the individual's employability and identifying suitable interventions to enhance their work readiness, showcasing the intersection of healthcare assessment and vocational planning found in both documents.
When dealing with the PA 635 form, it's essential to navigate the process correctly to ensure the assessment is accurately completed. This guidance provides a streamlined list of do's and don'ts to help you through. Here are ten insights to keep in mind:
Following these guidelines will help ensure that the PA 635 form is completed thoroughly and accurately, facilitating a smoother process for both the client and the county assistance office.
There are several misconceptions surrounding the PA 635 form, a crucial document used in Pennsylvania for assessing an individual's employment capabilities in relation to their health. Here are five common misconceptions and the truths behind them:
This is not accurate. While the form may be filled out by a counselor, social worker, or mental health therapist, it explicitly requires agreement and signature from a physician, psychologist, physician assistant, or certified registered nurse practitioner. The emphasis is on having these professionals validate the findings because they are legally authorized to make such assessments.
While determining disability status is a significant aspect of the PA 635 form, its purpose extends beyond that. It aims to assess whether an individual can participate in employment and training activities and what treatment plans could facilitate their movement towards employment, thereby encompassing a broader scope than just evaluating for disability benefits.
This misunderstanding could lead to incomplete assessments. The instructions indicate that if pregnancy does not affect the individual's ability to work, only Section I needs to be completed. However, if pregnancy impacts work ability, further sections of the form require completion to comprehensively evaluate the person's situation.
The form indeed facilitates an initial assessment, but it also outlines recommended treatment plans and follow-ups with specialists, implying the need for ongoing evaluations. This ongoing process ensures the individual's capabilities are continually assessed, and adjustments to their employment or training activities can be made as needed.
The form clearly states that the signature of the medical provider must be original and that rubber stamps, labels, or other reproductions are not acceptable. This ensures the authenticity and integrity of the assessment, reinforcing the form's legal and professional standards.
Understanding these misconceptions is vital for individuals and professionals handling the PA 635 form, ensuring accurate and effective assessments are made in line with the Department of Public Welfare’s requirements.
Filling out and using the PA 635 Form, a Medical Assessment Form issued by the Commonwealth of Pennsylvania Department of Public Welfare, requires attention to detail and an understanding of its significance. Here are key takeaways to guide individuals and medical providers through this process:
This guide underscores the vital role of PA 635 in bridging health assessments with employment eligibility, supporting individuals in their journey towards employment or acknowledging when medical conditions necessitate adjusted expectations.
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