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

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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:
Secondary:
Secondary:
Secondary:
Secondary:
Secondary:
Secondary:
Secondary:
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:
Date: ___/___/_______ (mm/dd/yyyy)
Dated signature is verification that information in Section B is accurate for this patient and authorization to conduct PCS eligibility
assessment.
DMA-3065
Revised 07/19/2012
FORM NOT VALID FOR USE AFTER DECEMBER 2012

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