How to Complete the PA Medical Assistance Application (PDF)

The Pennsylvania medical assistance Application is a document that you must complete in order to receive Medical Assistance

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The Pennsylvania Departments of Human Services (DHS) and Health (DoH) provide health care coverage through the Medical Assistance (MA) program to eligible low-income residents. This document will guide you through the process of completing the PA MA application.

The first step is to gather the required information and documents. You will need to provide proof of identity, residency, and income. You may also need to provide additional information depending on your situation.

Next, complete the application form. You can do this online, by mail, or in person at a DHS county office. If you are completing the form online, you will need to create an account and login.

Once you have submitted the completed application form, you will be contacted by DHS to schedule an interview. This interview can be done in person, by phone, or by video chat. During the interview, a DHS worker will ask you questions about your situation and verify the information on your application form.

Once your application is approved, you will be enrolled in the MA program and will receive a card in the mail that you can use to access covered services.

What you’ll need to complete the application

You will need the following information to complete the application:

-Your name, date of birth, Social Security number, address, and phone number
-Your spouse’s name and date of birth (if you are married and applying for Medical assistance for yourself and your spouse)
-The names, dates of birth, and Social Security numbers for any children who are under 21 or disabled and live with you
-Information about any health insurance you or your family have now
-Information about your job, job training program, or school if you are between 18 and 20 years old
-Your mortgage company’s name, address, and phone number (if you own your home)
-The name(s), address(es), and phone number(s) of someone we can contact if we cannot reach you

How to complete the application

In order to complete the application, you will need:
· Your 10-digit PA Medical Assistance number
· The name, address, and phone number of your doctor or clinic
· The name and phone number of your current drug plan, if you have one
· Your most recent pay stubs or other proof of income
· Your bank statement or a voided check (if you want direct deposit of your benefits)

You can complete the application online at, or you can download a paper application at and submit it by mail or fax.

What to do after you’ve completed the application

You’ve completed the application and gathered all required documentation. Now what? The next step is to submit your application to your county’s human services office for processing.


Frequently Asked Questions about completing the Pennsylvania Medical Assistance application (PDF).

Tips for a successful application

There are a few things you can do to ensure your application for PA medical assistance is successful:

-Complete the application in full and make sure all required documentation is included.
-If you are asked to provide documentation that you do not have, do your best to provide something similar.
-If you have any questions about the application process, reach out to a PA medical assistance representative for help.
-Be honest on your application. Inaccurate or incomplete information could lead to your application being denied.

More resources

If you need help filling out the application, contact your local County Assistance Office or the Department of Human Services at 1-800-692-7462.

Contact information

You’ll need to provide some basic information about yourself and your family when you apply for medical assistance. Be sure to have the following information handy:
-Your Social Security number
-Your bank account information (if you have one)
-The names, dates of birth, and Social Security numbers for each member of your household

Application checklist

Before you begin the application, gather the following items:
– Your 10-digit Personal Identification Number (PIN)
-Your social security number
-The social security numbers of any children in your household
– proof of U.S. citizenship or eligible non-citizen status (e.g. Birth certificate, passport, naturalization papers)
-Proof of Pennsylvania residency (e.g. mortgage or rental agreement, Pennsylvania driver’s license or state photo ID, utility bill)
-Proof of any income you or your household receive (e.g. pay stubs, Social Security award letter, child support award letter)
-Proof of any assets you or your household have (e.g. savings account statement, stock or bond certificates)


The PA Medical Assistance application is a very important document. It is used to determine your eligibility for medical assistance programs. The application must be completed in full and signed by you and your doctor.

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