Personal Care Services (Pcs) Supplement Form printable pdf download

Personal Care Services (Pcs) Supplement Form

Personal Care Services (PCS) Supplement Form

Personal care services are provided to help a child with a disability or chronic condition benefit from special education.

Personal care services include a range of human assistance provided to persons with disabilities or chronic conditions which

enables them to accomplish tasks that they would normally do for themselves if they did not have a disability. An individual

may be physically capable of performing activities of daily living (ADLs) and instrumental ADLs (IADLs) but may have

limitations in performing these activities because of a functional, cognitive, or behavioral impairment.

Student’s Name: ________________________________ DOB: _____/________/___________

Medicaid ID: ____________________________________

Medical condition requiring PCS: __________________________________________________

Type of Service

Group

Individual

Both

Episodic

Continual

(circle)

* please note: Individual services require a one-on-one aide

Frequency

Daily

Periodic

(circle)

Does this student require Behavioral Services due to an impairment?

YES

(circle)

Activities for daily living or Instrumental activities for daily living

Check appropriate tasks

Bathing

Dressing

Toileting/Diapering

Exercises

Eating/Feeding/Meal Preparation

Personal Hygiene

Laundry

Light housework/chores

Money management

Transferring/Escorting/Redirecting

Observation/Monitoring

Cueing/Prompting

Grocery Shopping

Other:

A statement must be made explaining the reason for the service, duration, and the location in

which the service will be provided.

Texas State Billing Services

Personal Care Services (Pcs) Supplement Form