Form Dma-3065 - Personal Care Services (Pcs) Medical Attestation For Licensed Care Home Residents - N.c. Department Of Health And Human Services

Download a blank fillable Form Dma-3065 - Personal Care Services (Pcs) Medical Attestation For Licensed Care Home Residents - N.c. Department Of Health And Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dma-3065 - Personal Care Services (Pcs) Medical Attestation For Licensed Care Home Residents - N.c. Department Of Health And Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

N.C. Department of Health and Human Services – Division of Medical Assistance

PERSONAL CARE SERVICES (PCS) MEDICAL ATTESTATION FOR LICENSED CARE HOME RESIDENTS

Completed attestation form serves as authorization to conduct PCS eligibility assessment of current licensed care home residents.

Licensed Home Provider: Present completed form to The Carolinas Center for Medical Excellence (CCME) RN Assessor at

time of resident assessment. If form is completed after resident’s assessment, send completed form to CCME via fax at 877-

272-1942, or mail to: CCME, ATTN: PCS Independent Assessment, 100 Regency Forest Drive, Suite 200, Cary NC 27518-8598.

(Forms for more than one resident may be bundled and sent together. Certified mail with delivery confirmation is recommended.)

Receipt may be confirmed with CCME at 800-228-3365. E-mail questions to .

PLEASE COMPLETE ALL FIELDS.

Section A. Resident Demographics—TO BE COMPLETED BY LICENSED CARE HOME PROVIDER

Medicaid ID#: __ __ __ __ __ __ __ __ __ __

Most Recent FL-2/MR-2 Date: ___/___/_______ (mm/dd/yyyy)

Resident Name (as shown on Medicaid Card) Last:

First:

MI:

Gender: ___Male ___Female

Date of Birth: ___/___/_______ (mm/dd/yyyy)

Primary Language: __English __Spanish __Other

Resident Phone: (______) ______ - _________

Current Residence (Facility Name):

Facility License Number:

License Date: ___/___/_______ (mm/dd/yyyy)

Facility Fax Number: (______) ______ - _________

Facility Type: ___Family Care Home ___Adult Care Home ___SLF-5600a ___SLF-5600c ___Adult Care bed in Nursing Facility

Does Resident Have a Legal Guardian? ___Yes ___No

If Yes, Guardian Last Name:

First Name:

Phone: (______) _____ - _________

Section B. Resident Information—TO BE COMPLETED OR VERIFIED BY ATTESTING PRACTITIONER

List conditions that currently limit resident’s ability to independently perform Activities of Daily Living (bathing, dressing, mobility, toileting, eating),

prepare meals, and manage medications:

Primary Diagnosis:

Secondary:

Conditions listed are: ___Chronic Medical

___Physical Disability

___Mental Illness

___MR/Developmental

___Dementia

(check all that apply)

In the absence of caregivers, is resident at risk of any of the following? (check all that apply):

___Falls

___Malnutrition

___Skin Breakdown

___Adverse Consequences of Medication Non-Compliance

Is 24-hour caregiver availability required to ensure resident safety? ___Yes ___No

(e.g., Does resident have unscheduled ADL needs or require safety supervision or structured living, or is resident unsafe if alone for extended periods?)

Section C. Attesting Practitioner Information—TO BE COMPLETED BY ATTESTING PRACTITIONER—RETURN SIGNED FORM

TO LICENSED HOME PROVIDER

Practitioner Last Name: ____________________________ First Name: _________________________ NPI#:

Attesting Practitioner: ___PCP/Attending MD ___NP ___PA

Date of Resident’s Last Visit with Attesting Practitioner: ___/___/_______ (mm/dd/yyyy)

Practice Name:

(if applicable)

Office Contact Last Name:

First:

Position:

Phone: (______) ______ - __________ Fax: (______) ______ - _________ E-mail:

Practitioner Signature: