MedicaidAdministrativeLow impact
d 004602
Pennsylvania Medicaid (DHS)·PA·Provider Bulletin
Effective date
Dec 1, 2006
We identified it
Jun 20, 2026
Summary
The Pennsylvania Department of Public Welfare has revised the Citizenship and Identity Information Form (PA 1809) used for Medicaid applications. The updated form now includes fields for gender and State Identification Card number and is available in both English and Spanish.
Action Required
Immediately: Administrative staff should begin using the revised PA 1809 Citizenship and Identity Information Form (dated 12/06) when assisting Medicaid applicants who cannot provide required citizenship/identity documents. Download the updated form from the bulletin attachment and make photocopies for continued use until COMPASS system is updated.