This government document is issued by Human Services for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:yqjcmted-sw&q=https://www.dhs.pa.gov/providers/Providers/Documents/Business%2520and%2520Tech%2520Standards/Appendices/c_293641.docx&sa=U&ved=2ahUKEwjqr6WC9PCFAxUw_7sIHXw_DG04HhAWegQIAxAB&usg=AOvVaw1tuK4sDFwUvfawfy3mc_wz&arm=e