Resources

Forms

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Case Management Services

• Mental Health Advance Directive
  (Developed by the UPenn Collaborative on Community Integration)

• Release of Information Form
• Limited Power of Attorney Form

Trust Services

• Master Trust Document w/1st Amendment
• Adoption/Joinder Agreement
• Request for Funds from Trust Form

Representative Payee Services

• Application for Representative Payee Services
• Creating a budget for a new Representative Payee Client
• Request for Funds from Checking Account
• SSA Form 4164. This form must be filled out naming PLAN of PA as your designated Organizational Representative Payee.

• SSA Form 787 Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits. (This form only needs to be filled out if you do not currently have a designated Representative Payee.)

 

Mail completed forms to:

• PLAN of PA
  P.O. Box 154
  Wayne, PA 19087