Rights & Responsibilities

• I understand that Pennsylvania receives information from the Income Eligibility Verification System (IEVS), financial institutions, consumer reporting and state and federal agencies to verify the information I give them. Information available through IEVS and other entities will be requested, used and may be verified through collateral contact when conflicting details are found by the State agency, and such information may affect my household’s eligibility and level of benefits.
• I understand that by signing this application, I am authorizing any financial institution to disclose, through electronic or any other means, any and all financial information held by that institution, to the Department of Human Services or its designated agent or contractor for the purpose of identifying and verifying assets when needed to determine and re-determine eligibility for Medical Assistance. I understand that financial information includes deposits, withdrawals, account closures and other relevant information requested or received from the financial institution, including other transactions undertaken by the financial institution with respect to the account or asset. I understand that this authorization is effective until Medical Assistance eligibility is denied or ends, or if I decide to revoke it by written notification to the Department, whichever happens first. I understand that if I revoke this authorization, that may make me or my household ineligible for Medical Assistance.
• I understand that if I misrepresent, hide or withhold facts that may affect my eligibility for benefits, I may be required to repay my benefits and I may be prosecuted and disqualified from receiving certain future benefits.
• I understand that I can designate an authorized representative by completing the Authorized Representative section and submitting it with this application.
• I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is submitted by someone acting on my behalf.
• I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.
• I understand that the Department of Human Services or its designees may contact me via methods including email and text messaging to help process my application or request feedback on the application process. If I do not want email or text messages, I understand the Department will still process my application.
• I understand that the information entered in this application will be kept confidential and only to administer benefits. I authorize the release of personal, financial and medical information for the purpose of determining eligibility.
• I understand that any changes I am required to report must be reported within the first 10 days of the month following the month of change.
• I understand that my household may lose SNAP benefits if a household member receives lottery or gambling winnings equal to or greater than the SNAP resource limit for elderly or disabled households.
• I understand that I will receive a written notice explaining the benefits. If benefits are denied, changed, suspended or stopped, the written notice will explain why.
• I understand that I will have 30 days (90 days for SNAP (food stamp) benefits) from the date of the notice to request a hearing if I do not agree with the decision made on this application.
• I understand that my situation is subject to verification from employers, financial sources and other third parties.
• I understand that applicants must provide their Social Security number or apply for one if they do not have one. This number may be used to check the information on this application.
• I understand that I must use the Electronic Benefit Transfer (EBT) or the PA ACCESS Card only during the period I am eligible. I must use the EBT or the PA ACCESS Card only for the person who is eligible and may get only the benefits that are needed and reasonable.
• I understand that I may not use Cash Assistance funds issued through my PA ACCESS card to make EBT transactions in liquor stores, casinos (gambling casinos, gaming establishments), or places for adult entertainment.
• I understand that I am required to report lottery and gambling winnings.
• I understand that I do not have to provide a Social Security number for anyone who is not applying for assistance. If I do provide their Social Security number, it may be used to check the information on this application.
• I certify that all information that has been entered is true under penalty of perjury.
• I understand that I have the right to a certificate of creditable coverage to verify my medical coverage. Federal law limits when health care coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition clause, I can get credit for the time I received Medical Assistance.
• I understand that if I am determined eligible for Medical Assistance, I will be placed in the most comprehensive health care benefit package that is available to me. I understand that I may be required to enroll in a health plan. I understand that enrolling in a health plan may be free or low cost to me, because the Department pays a monthly fee to the health plan for me. I understand that the monthly fee is a capitation fee. I understand that if I receive Medical Assistance that I am not eligible for, due to error, fraud, or any other reason, then I may be required to repay the Department all monthly fees paid on my behalf.
• If I receive cash benefits, I will cooperate with the requirements of the child support enforcement program as directed by the Department. I give the Department and the Domestic Relations Section the right to pursue and collect cash and/or medical support for me and others for whom I am applying.
• I understand that if I report and provide proof of the household expenses, I will get the maximum amount of SNAP (food stamp) benefits allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproved expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Notice 6-99, issued January 4, 1999).
• I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (food stamps) certification period.
• I understand that I have the right to ask the county assistance office (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for confirmation if I am having trouble getting proof of anything
• I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for CHIP. If this is the case, I authorize the Department of Human Services to give my name and information on this application to a CHIP contractor.
• I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for federal benefits and/or explore private health care options through Pennsylvania's Health Insurance Marketplace (Pennie). If this is the case, I authorize the department to give my name and information on this application to Pennie.

CHIP

You have a right to:

• Confidentiality - All information on this application will be kept confidential. This application will be shared only with the government programs for which you apply and/or may be eligible, such as Medical Assistance and Pennie premium assistance.
• Designate a Personal Representative - You may select another person to receive health related information regarding you or your minor child(ren) by completing a Personal Representative Designation form.
• Certificate of Creditable Coverage - When you leave the program, you will receive a certificate of creditable coverage to verify medical coverage, if you are eligible.
• Written Notice - You will be given a written notice explaining your eligibility.
• Appeal - You may request an impartial review if you do not agree with any decision made regarding this application, if the request is made within 30 days of the decision.

You have a responsibility to:

• Read and fully understand this application.
• Provide true, correct and complete information, understanding that there are penalties for knowingly giving false information: it is a serious offense and considered criminal insurance fraud.
• Help with the review of this application, which may include interviews and reviewing health records.
• Be aware that certain information may be subject to verification from employers, financial sources and other third parties.
• Provide proof of identity and U.S. citizenship if that information is not obtained through this application process.
• Provide proof of legal immigration status by presenting documentation from the U.S. Citizenship and Immigration Services if you are applying for someone who is not a U.S. Citizen.
• Report all changes regarding your household including income, address and telephone number as soon as they occur.

I understand:

• If some or all of the individuals applying do not qualify for CHIP, that they may be eligible for Medical Assistance. If this is the case, I authorize the CHIP Contractor to give any and all information found on this application to the Department of Human Services. I understand my rights and responsibilities under Medical Assistance.
• If some or all of the individuals applying do not qualify for CHIP, that they may be eligible for federal benefits and/or explore private health care options through Pennsylvania's Health Insurance Marketplace (Pennie). If this is the case, I authorize the Department to give any and all information on this application to Pennie. I understand my rights and responsibilities under Pennie.
• If it is determined that my child is eligible for or enrolled in state employees’ health care benefits from a public agency and the agency would pay even a small portion of the benefit or premium cost, then my child is not eligible for CHIP. If this is the case and my child has been receiving CHIP benefits, my child’s CHIP benefits may be retroactively terminated.

Pennsylvania's Health Insurance Marketplace (Pennie)

• I certify that all information that has been entered is true under penalty of perjury. I know that I may be subject to penalties under federal law if I knowingly provide false and/or untrue information.
• I know that I must tell Pennie if anything changes (and is different than) what I wrote on this application. I can visit Pennie.com or call 1-844-844-8040 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household.
• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting hhs.gov
• I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed).
• Renewal of coverage in future years: To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Pennie to use my income data, including information from tax returns. Pennie will send me a notice, let me make any changes, and I can opt out at any time.

All Health Care Programs

• I certify that, to the best of my knowledge, I understand my rights and responsibilities and that the information included in this application is complete and true under penalty of perjury. I also certify that knowingly providing false or incomplete information on this application is insurance fraud.
• I understand that I can designate an authorized representative by completing the Authorized Representative section and submitting it with this application.
• I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is submitted by someone acting on my behalf.
• I understand that all individuals applying will be provided access to coverage under the program for which they are eligible, if they are found eligible for Medical Assistance, CHIP or federal benefits through Pennie.
• I will allow the Department of Human Services to give my name and information on this application to the CHIP contractor if any applicants may be eligible for CHIP.
• I will allow the CHIP Contractor to give any and all information found on this application to the Department of Human Services if any applicants may be eligible for Medical Assistance.
• I understand that I do not have to provide a Social Security number for anyone who is not applying for assistance. If I do provide their Social Security number, it may be used to check the information on this application..
• I certify that all information that has been entered is true under penalty of perjury.
• I certify that the person(s) I am applying for are U.S. citizens or aliens in lawful immigration status.

Supplemental Nutrition Assistance Program (Food Stamps) Rights & Responsibilities

• I understand that if I report and provide proof of the household expenses, I will get the maximum amount of SNAP (Food Stamps) benefit allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproven expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Note 6-99, issued January 4, 1999).
• I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (Food Stamps) certification period.
• I understand that I have the right to ask the County Assistance Office (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for confirmation if I am having trouble getting proof of anything.
• In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Long Term Care and Home and Community-Based Services Rights & Responsibilities

• If I am age 55 or older and receive Medical Assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, it will be required that my probate estate be used to repay the cost of these services.
• If I do not report changes as required, my benefits may be reduced or stopped. If I purposely fail to give correct information or report changes, I may be fined and/or put in jail.

Low-Income Home Energy Assistance Program (LIHEAP) Rights & Responsibilities

• My signature on this application gives my permission to the Department of Human Services or its authorized agent to: (a) check any information I give about where I live, my jobs, income, resources, energy supply and energy supplier; (b) share information with my energy supplier and receive information from my energy supplier to allow DHS to obtain a record of my annual energy consumption, cost and billing information for purposes of program evaluation, operation, or reporting; and (c) complete any survey in connection with energy assistance.
• I authorize the release of LIHEAP eligibility information to and from my energy suppliers or weatherization agencies and allow them to seek assistance for which I may be eligible. The assistance may include LIHEAP Cash, Crisis, or Weatherization benefits.
• I understand I have the right to appeal any decision or undue delay in decision which I consider improper regarding this application.
• I affirm that Pennsylvania is my legal residence.
• I understand any Social Security number(s) given will be used in the administration of this program, including cross matches with other programs.
• I understand that I will be sent a notice of eligibility or ineligibility and, if eligible, the notice will state the amount of my benefit.
• I further understand that if my household is eligible for a LIHEAP cash benefit, it must be sent directly to my utility company or fuel dealer unless I am a renter and my heat is included in my rent or my fuel is supplied by a fuel dealer who does not accept vendor payment.
• I certify that, subject to penalties provided by law, the information I gave is true, correct and complete to the best of my knowledge.
• I know that if I give false information, I can be penalized by fine and/or imprisonment.
• I understand by signing this application, I may not qualify because LIHEAP money has run out.

National School Lunch Program Rights & Responsibilities

• I understand that an incomplete application cannot be approved for benefits. Be sure to fill out all required information.
• I understand that my income may be verified (checked).
• I certify that all the information is true and accurate.
• I understand that if I purposely give false information, my children may lose meal benefits.
• I understand that I may be fined and/or imprisoned for providing false information.
• I may apply for meal benefits at any time throughout the school year.
• I may ask for a hearing if I do not agree with the school's decision regarding the school meals application.
• I understand that this information is to be kept confidential and used only for the purposes intended (School Meals, Title I, PSSA tests, certain NCLB reports, etc.) unless confidentiality is waived.

Child Care Works Rights & Responsibilities