The PA 1663 form is the Employability Assessment Form that the Pennsylvania Department of Human Services (DHS) uses to document a physical or mental disability that temporarily or permanently prevents a public assistance applicant from gainful employment, for General Assistance (GA). The applicant completes Section I; a licensed physician, physician's assistant, certified registered nurse practitioner or psychologist completes Section II. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original form is published by DHS, and the signature must still be made in original ink by the person who performed the assessment.
Last updated
What is PA 1663?
Employability Assessment Form PA 1663 is the Pennsylvania Department of Human Services (DHS) form that documents whether an applicant for public assistance has a disability that precludes gainful employment, so DHS can assess qualification for General Assistance (GA).
The form has two sections. Section I is completed by the applicant or recipient: personal details, a brief explanation of why they believe they cannot work, and a signed authorization for medical providers to release information related to employability to DHS. The information is used only to assess the ability to work and eligibility for public assistance.
Section II is completed by a licensed physician, physician's assistant, certified registered nurse practitioner or psychologist. The provider checks only one employability category:
- Permanently Disabled, a disability that permanently precludes any gainful employment; the patient is a candidate for Social Security Disability or SSI.
- Temporarily Disabled – 12 months or more, with the start date and the expected end date.
- Temporarily Disabled – less than 12 months, with the start date and the expected end date.
- Employable, when the patient's condition allows work.
When one of the disability boxes is checked, the provider must also give the diagnosis (primary and secondary) and the basis of the assessment. A diagnosis alone is not enough: the instructions on the form require information about the basis for the diagnosis and assessment.
Who needs to file PA 1663?
The main group is applicants for public assistance who claim a physical or mental disability that temporarily or permanently precludes any gainful employment and who may be eligible for GA. DHS asks for this form for an applicant for public assistance, and the applicant completes Section I.
Section II must be completed by one of four types of providers only:
- a licensed physician (medical doctor or doctor of osteopathy);
- a physician's assistant;
- a certified registered nurse practitioner;
- a psychologist.
Only the individual who performed the employability assessment may sign Section II. Another person cannot sign for the provider, and signature or clinic stamps, labels and other facsimiles are not acceptable; a form without an original signature is invalidated.
The form states that GA benefits cannot be authorized for the applicant until the fully completed form is returned to the county assistance office worker. Questions go to the local county assistance office.
When to file PA 1663
The triggering event is an application for public assistance in which the applicant claims a disability that prevents work. After completing Section I, the applicant arranges an appointment with a licensed physician, physician's assistant, certified registered nurse practitioner or psychologist. The form states that GA benefits cannot be authorized until the fully completed form is returned to the county assistance office worker, so return it as soon as the provider has finished Section II.
The form prints no calendar deadline. Delay comes from problems with the form itself: if material cannot be read or questions are not fully answered, the client's application is delayed and the form is returned to the provider for clarification or completion. The Temporarily Disabled boxes ask for the date the disability began and the date it is expected to end.
Documents you need
- Supporting medical documentation, such as medical records, X-rays and lab reports, sufficient to support the provider's decision; it must be available for DHS review if required, and is not listed as a mandatory attachment.
- Any attachments the provider includes with Section II must be complete and legible; the instructions ask that they be typed if possible.
How to fill out PA 1663
Review the case identification block
At the top, the county assistance office (CAO) name and address, case identification (CO, record number, CAT, CSLD, DIST), record name and date, and worker are the office's entries. Leave them as printed unless the office tells you otherwise.
Check your personal details in Section I
Review the printed name, birthdate, Social Security number, address, city, state, ZIP code and telephone number. If anything is wrong, strike it out and write the correct information clearly.
Explain why you cannot work
In the space for Briefly explain why you believe you cannot work, describe your condition in your own words.
Sign the medical release
Sign the authorization for medical providers to release information related to your employability to DHS, print your name and enter the date.
Take the form to a qualified provider
Arrange an appointment with a licensed physician, physician's assistant, certified registered nurse practitioner or psychologist, who completes Section II.
Check one Employability box
The provider checks only one: Permanently Disabled, Temporarily Disabled – 12 months or more, Temporarily Disabled – less than 12 months or Employable.
Enter the temporary disability dates
For either Temporarily Disabled box, enter the date the disability began and the date it is expected to last until.
Give the diagnosis
Under Examination Results item 1, enter the primary and secondary diagnosis. This is required if box 1, 2 or 3 is checked.
Mark what the assessment is based on
Under item 2, check all that apply: A. Physical Examination, B. Review of Medical Records, C. Clinical History, D. Appropriate Tests and Diagnostic Procedures, or E. Other (specify).
Complete the provider certification
The provider prints their name, telephone number and address, and enters the Medical Assistance Provider No. and date beside the signature.
Review, sign and download the PDF
Check that every required entry is complete and legible. Download or print the completed PDF from FillingPDF, then have the provider sign it in original ink and return it as described under How to submit.
How to submit PA 1663
The completed form goes back to the county assistance office (CAO) worker handling the applicant's case; the printed RETURN TO: area on the form identifies the office, and no other channel is printed on it.
- Return to the county assistance office: after the provider finishes Section II and signs it in original ink, the applicant returns the fully completed form to the CAO worker. Contact your local county assistance office with any questions about how it accepts the form.
- Keep it legible: the form and any attachments must be complete and legible, and should be typed if possible. If staff cannot read the material, the application is delayed and the form is returned for clarification.
The provider's supporting records, such as medical records, X-rays and lab reports, are not described as attachments; they must be available for review by DHS if required. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Having the form signed by someone other than the person who performed the assessment, or using a signature stamp, clinic stamp or label; only an original signature is accepted and a form without one is invalidated.
- Letting a provider outside the four listed types perform the assessment; only a licensed physician, physician's assistant, certified registered nurse practitioner or psychologist may do so.
- Checking more than one box under Employability; the form says to check only one.
- Giving only a diagnosis; the instructions require the basis for the diagnosis and assessment, and both parts of Examination Results must be completed.
- Leaving Examination Results incomplete when Permanently Disabled or either Temporarily Disabled box is checked; the form states the client will be ineligible for GA.
- Leaving questions unanswered or handwriting illegibly, which delays the application and returns the form to the provider.
- Not striking out incorrect pre-printed information in Section I and writing in the correct information.
- Omitting the start date or expected end date on a Temporarily Disabled box.
Frequently asked questions
What is the PA 1663 form used for?
The PA 1663 form is the Pennsylvania DHS Employability Assessment Form. It documents a physical or mental disability that temporarily or permanently precludes gainful employment, so DHS can assess an applicant's qualification for General Assistance (GA).
Who can complete Section II of PA 1663?
Only a licensed physician, physician's assistant, certified registered nurse practitioner or psychologist can perform the assessment. Only the individual who performed it may sign the form.
Can I fill out the PA 1663 form online?
You can fill out the PA 1663 PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file the form with DHS. The provider's signature must be original, so print it for signing.
Can a clinic stamp or typed signature be used on PA 1663?
No. The instructions say the signature must be original or the form will be invalidated, and signature or clinic stamps, labels and other facsimiles are not acceptable.
Where do I return the completed PA 1663?
Return the fully completed form to your county assistance office worker. The form says GA benefits cannot be authorized until it is returned. For questions, contact your local county assistance office.
What is the difference between the temporary and permanent disability boxes?
Permanently Disabled means a disability that permanently precludes any gainful employment. The two Temporarily Disabled boxes cover conditions expected to last 12 months or more, or less than 12 months, with start and end dates; the patient can work once the condition resolves.
What happens if the form is incomplete or illegible?
The client's application is delayed and the form is returned to the provider for clarification or completion. If Examination Results are not completed when a disability box is checked, the form states the client will be ineligible for GA.
Is a diagnosis enough on the PA 1663?
No. The instructions say simply providing a diagnosis is not sufficient. The provider must give the basis for the diagnosis and assessment, and supporting records such as X-rays and lab reports must be available for review if required.
Ready to fill out PA 1663?
Fill out PA 1663 now