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PA CD 878 Medical Assessment Form (Child Care Works)

Pennsylvania's subsidized child care program (Child Care Works) uses this two-page form when a parent's disability affects eligibility. The Early Learning Resource Center (ELRC) needs to know the diagnosis, whether the disability is permanent, and whether it prevents the parent from working or training, or from caring for the children for whom subsidy is requested.

Who completes it

A physician or psychologist completes Section Two and signs with printed name, title and the date completed. Section One is completed and signed by the parent with the disability, authorizing disclosure to the ELRC on behalf of the Department of Human Services.

Submitting and payment

How to submit it
Return the completed form to the Early Learning Resource Center named in the 'Return to' box on page 1.

Good to know

  • There are two separate determinations: whether the condition prohibits work, education or training, and whether it prohibits caring for the children; each needs an explanation and expected end date.
  • List the names and ages of the patient's children in the child care section so the ELRC can match the answer to the subsidy request.
  • The form also asks for the date of the last examination and the next scheduled appointment.
  • The current edition is printed CD 878 06/18; the ELRC fills in its name, record number and staff contact at the top.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Assessment Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign Pennsylvania's CD 878 Medical Assessment Form?

Section Two must be completed by a physician or psychologist. The signer prints their name and title, adds address and phone, and signs and dates the form. The parent with the disability completes and signs Section One separately.

What does the CD 878 ask about the parent's disability?

The diagnosis causing the disability, whether it is permanent, whether it does or does not prohibit working or participating in education or training, whether it prohibits caring for the children for whom subsidy is requested, how it affects each, and the expected date each inability will end.

Where does the CD 878 go when completed?

To the Early Learning Resource Center listed in the 'Return to' box on page 1. The ELRC acts on behalf of the Pennsylvania Department of Human Services in assessing the parent's eligibility for subsidized child care.