What does the physician attest to on the SPBP-MH application?

That by signing and by entering the ICD-10-CM diagnosis of schizophrenia on the attached prescription, the information is true, accurate and based on personal knowledge, that payment for the antipsychotic will be sought from state funds, and that misrepresentation may bring civil or criminal penalties.

How long is an MH 821 application valid after signing?

The application must be received no more than 30 days after the applicant and physician sign and date it. Missing information delays processing, which takes up to 30 days, and the program notifies applicants in writing rather than by phone.

Can someone on Medicare apply for SPBP-MH?

Yes. People eligible for Medicare Part A or B should enroll in Part D and apply to SPBP-MH to cover premiums, copays and deductibles for covered drugs. Applicants with other drug insurance can also apply; SPBP-MH is the payer of last resort.

PA MH 821 SPBP-MH Application (Antipsychotics)

Who completes it

The prescribing physician signs and dates the Section 8 Attestation Statement and enters their license number. The applicant, guardian or power of attorney completes Sections 1 through 7, including income, insurance and the certification.

Submitting and payment

How to submit it: The applicant mails the application and copies of required documents to the DHS OMHSAS Business Partner Support Unit, SPBP-MH Program; it must arrive within 30 days of the signatures.

Good to know

The physician who signs Section 8 must be the same physician who writes the prescription attached to the application.
The original prescription must show date of issue, patient name, medication, diagnosis code and written description, and the prescriber's name, address and license number.
Medical Assistance recipients, including HealthChoices members, are not eligible and should not apply; SPBP-MH pays last after Medicare Part D or other drug coverage.
The formulary lists Abilify, Clozaril, clozapine, Geodon, Invega, Risperdal, risperidone, Seroquel and Zyprexa; processing takes up to 30 days.

Get the official form

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

Special Pharmaceutical Benefits Program Application (SPBP-MH)

Official page PDF

All Social services forms

PA 1663

Employability Assessment Form

Examining provider's determination that a public assistance applicant/recipient is permanently disabled, temporarily disabled (12+ months or under 12 months) or employable, with diagnosis and basis, used by the County Assistance Office for disability-based eligibility and work-requirement exemptions.

Completed by: Licensed physician (MD/DO), physician assistant, certified registered nurse practitioner or psychologist who performed the assessment
Issued by: Pennsylvania Department of Human Services (DHS), Office of Income Maintenance
Format: Fillable PDF
Language: English

Official page PDF How to fill it in

CD 878

Medical Assessment Form

Physician or psychologist statement of a parent's disability and whether it prevents working/training or caring for the children, used by the Early Learning Resource Center to decide subsidized child care eligibility.

Completed by: Physician or psychologist
Issued by: Pennsylvania Department of Human Services (DHS), Office of Child Development and Early Learning (Child Care Works subsidy)
Format: Fillable PDF
Language: English

Official page PDF Form details

2941-EF

Medical Provider ABAWD Attestation

Licensed medical professional's statement of whether a SNAP able-bodied adult without dependents (ABAWD) can do 80 hours/month of work activities, and whether limits are temporary or permanent, for the ABAWD work-requirement exemption.

Completed by: Licensed medical professional
Issued by: Nevada Department of Human Services, Division of Social Services (DSS, formerly DWSS)
Format: Fillable PDF
Language: English and Spanish

Official page PDF Versión en español Form details

CW 61

Authorization to Release Medical Information (CW 61 Medical Report)

Autorizacion para Divulgar Informacion Medica

Documents whether a CalWORKs/CalFresh applicant or participant has a medically verifiable physical or mental condition that limits or prevents work, training or education, its expected duration, and whether someone must be home to care for them, so the county can exempt the person or assign suitable welfare-to-work activities.

Completed by: Licensed physician or certified psychologist, or another health care professional licensed/certified to diagnose and treat (MD, DO, chiropractor, psychologist), as checked by the county worker
Issued by: California Department of Social Services
Format: Fillable PDF
Language: English and Spanish

Official page PDF Versión en español How to fill it in

DCF-F-DWSP2012-E

Medical Examination and Capacity

Medical professional's report of a Wisconsin Works (W-2) participant's conditions, work/training capacity and accommodations, used by the W-2 agency to assign activities and decide placements.

Completed by: Medical professional treating or examining the participant
Issued by: Wisconsin Department of Children and Families (DCF), Division of Family and Economic Security
Format: Word document
Language: English

Official page Word file Form details

DHS-49

Medical Examination Report

Treating physician's examination findings, diagnoses and physical limitations used by MDHHS's Disability Determination Service (DDS/MRT) to certify disability for State Disability Assistance (SDA), FIP deferrals and Medicaid disability.

Completed by: M.D. or D.O. (treating physician)
Issued by: Michigan Department of Health and Human Services
Format: Sent for each case
Language: English

Official page Form details

Fill it with Vero

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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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