DHS-4292-ENG 1-25 (1.3.0)

PERSONAL CARE ASSISTANCE (PCA)

PCA Request Form

Lead agencies use this form to request technical changes or corrections to existing approved PCA service agreements (SA). Use this form only when corresponding PCA assessment data already has been entered in MMIS. All other requests will be denied.

I ATTEST I AM A COUNTY, TRIBAL, OR CONTRACTED ASSESSOR AGENCY STAFF AUTHORIZED TO MAKE THIS CHANGE REQUEST

TODAY'S DATE

SERVICE AGREEMENT NUMBER

ASSESSMENT DATE

Request type

What type of change is this?

Technical Change/Correction to existing SA

Report initial choice of provider

Update to PCA Choice Option

Add shared care option

Other

Technical Change/Correction to existing SA

Description of Change or Correction

Report initial choice of provider

FIRST DATE OF SERVICE

PROVIDER NAME

PROVIDER NPI or UMPI

Is this a consolidated provider?

Yes

I don’t know the taxonomy code (provider type and address required)

TAXONOMY CODE

PROVIDER TYPE

FULL ADDRESS

Other

Description of Change Request

Member Information

LAST NAME

FIRST NAME

8 Digit MEMBER ID (also known as PMI number)

DATE OF BIRTH

May Select PCA Choice

Yes

Does the member require a Responsible Party?

Yes

Lives with Member

Yes

RESPONSIBLE PARTY'S NAME

Service Request

T1019 Personal Care Assistance (PCA)

Authorized For Flexible use

Yes

TOTAL UNITS ALLOCATED TO 1ST DATE SPAN

START/CHANGE DATE (1st SPAN)

END DATE (1st SPAN)

TOTAL UNITS ALLOCATED TO 2nd DATE SPAN

START/CHANGE DATE (2nd SPAN)

END DATE (2nd SPAN)

Assessed PCA units will be split evenly into one month spans

TOTAL UNITS ALLOCATED

START/CHANGE DATE

END DATE

T1019 TG Personal Care Assistance (PCA) Complex

Authorized For Flexible use

Yes

Assessed PCA units will be split evenly into one month spans

TOTAL UNITS ALLOCATED

START/CHANGE DATE

END DATE

TOTAL UNITS ALLOCATED TO 1ST DATE SPAN

START/CHANGE DATE (1st SPAN)

END DATE (1st SPAN)

TOTAL UNITS ALLOCATED TO 2nd DATE SPAN

START/CHANGE DATE (2nd SPAN)

END DATE (2nd SPAN)

T1019 UA Supervision of PCA

TOTAL UNITS

START/CHANGE DATE

END DATE

PROVIDER NAME

PROVIDER NPI or UMPI

Requestor's Information

NAME OF REQUESTOR

TITLE OF REQUESTOR

PHONE NUMBER

LEAD AGENCY

ASSESSOR AGENCY ORGANIZATION NAME

ASSESSOR AGENCY NPI/UMPI

PCA Request Form

Request type

Technical Change/Correction to existing SA

Report initial choice of provider

Other

Member Information

Service Request

Requestor's Information

Additional Information