PO Box 8806
Harrisburg, PA 17105-8806
Select a category to indicate who is filling out the application:
Area Agency on Aging
Benefits Data Trust
Family Member / Friends
Medical Care Facility
Please click on one of the boxes to indicate who is filling out the application.
Please choose 'Other' if you do not fall into any of the categories listed.
When you are done, click on 'Continue'.