Time Limit Medical Exemption Form - Coalition Against Hunger printable pdf download

ABAWD Time Limit

Medical Exemption Form

Dear Medical Provider:

The Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp program), limits

Able-Bodied Adults without Dependents (ABAWD) to only 3 months of SNAP within 36 months. This

rule applies unless the adult is working a minimum of 20 hours per week or is exempt from the time

limit because the individual is medically certified as physically or mentally unfit for employment or falls

within another exemption. Please help us determine whether your patient meets the exemption due to

medical or mental issues and can be exempted from the ABAWD provisions.

Patient’s name:

Date of birth:

Patient/participant’s authorization:

I hereby authorize the release of the medical information and/or rehabilitation participation requested to the

Pennsylvania Department of Human Services.

Signature:

Date:

Please answer one or more of the following questions in the box below. Please sign and date this form

including your title or position in your agency*.

Is this individual pregnant?

Yes

If yes, due date?

2. Is this individual a participating in drug/alcohol treatment or counseling program; mental health

counseling program; or a vocational rehabilitation program?

Yes

If yes, specify program:

Is this program ongoing?

Yes

If no, date program will end:

3. Does this patient have a mental and/or physical illness or disability which reduces his or her ability to

financially support him or herself?

Yes

If yes, specify disability:

Is this condition ongoing?

Yes

If no, date it is expected to end:

I certify that the information provided above is true and accurate.

Name (please print)

Title/profession*

Signature

Date form signed

Address and phone number

This form may be signed by any of the following: physician, physician’s assistant, designated representative of the physician’s office,

nurse practitioner, osteopath, psychologist, drug and alcohol abuse counselor, mental health counselor, social worker, midwife, podiatrist,

audiologist, physical therapist, occupational therapist, optometrist, or any other medical personnel whose services may be reimbursed

by Medical Assistance.

PA 1921 12/15

Time Limit Medical Exemption Form - Coalition Against Hunger

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