PCA Technical Change Request

PCA service providers use this form to request a technical change to an existing, approved PCA service authorization (SA) for the person who receives services.

Complete and submit the Referral for Reassessment for PCA/CFSS Services, DHS-6893B (PDF) to the lead agency to request a new authorization or report a change in condition.

For use by providers of PCA services only.

Service agreement

CHANGE/START DATE

END DATE

Member information

LAST NAME

FIRST NAME

8 DIGIT MEMBER ID (also known as PMI number)

DATE OF BIRTH

PCA OPTION (the option the person will use with your agency)

PCA Traditional

PCA Choice

Member or responsible party signature

NAME OF PERSON WHO SIGNED RELEASE

DATE OF SIGNATURE

RELATIONSHIP TO MEMBER (if member is their own responsible party, enter self)

As the provider, I have received/maintained the signature of the responsible party requesting this change.

Additional information

Provider agency information

PROVIDER NAME

PROVIDER NPI or UMPI

Are you a consolidated provider?

Yes

TAXONOMY CODE

I don't know my taxonomy code (provider type and address required)

PROVIDER TYPE

FULL ADDRESS

NAME OF REQUESTOR

TITLE OF REQUESTOR