Employment and Career Interest Form

Which PA Health and Wellness plan are you with? * Community HealthChoices (Medicaid) Wellcare (Medicare) I have both Medicare and Medicaid with PA Health and Wellness.

What is your current employment status? Select all that apply. * Employed Seeking Work In School or Training Retired Other

How many average hours per week do you work?* * Less than 20 hours 20-37.49 hours 37.5+ hours I am self-employed and do not know. I choose to not disclose. I am trying to find work. I’m not currently working.

Select which applies.: * I am interested in support available to me to find work. I have a job, but would like support. I have a job, but want a different one. I have a job and would like to connect with a certified benefits counselor. I am interested in benefits counseling to learn more about working and benefits. I do not want support at this time.

Did Participant Services assist you with finding or completing this form? * Yes No

PA Health and Wellness Employment and Career Interest Form

Participant Information

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