Acceptable verification of circumstances relating to a decrease in copayment includes any of the following:

1. (1) Verification of a decrease in income as specified in § 3042.65 (relating to verification of income).
2. (2) Verification of a change in family size and composition as specified in § 3042.71 (relating to verification of family size).

3. (3) Verification of maternity and family leave as indicated by one of the following:

   1. (i) A birth certificate.
   2. (ii) The Department’s medical assessment form.
   3. (iii) A medical record or a written statement from a licensed physician, physician’s assistant, CRNP or psychologist.
   4. (iv) A written statement or other documentation completed by a licensed physician, physician’s assistant, CRNP or psychologist that describes the inability to work or participate in education or training and includes a date of anticipated return to work.
   5. (v) A written statement from the employer or an education or training representative.
   6. (vi) A collateral contact as specified in § 3042.62 (relating to collateral contact).
   7. (vii) A written self-declaration by the parent or caretaker as specified in § 3042.64 (relating to self-declaration).
4. (4) Verification relating to inability to work due to a disability as specified in § 3042.70 (relating to verification of inability to work due to a disability).

Cross References

This section cited in 55 Pa. Code § 3042.145 (relating to domestic and other violence); and 55 Pa. Code § 3042.146 (relating to homelessness).