Form Dma-3066 - Independent Assessment Request For New Admissions - North Carolina Department Of Health And Human Services
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1N.C. Department of Health and Human Services – Division of Medical Assistance
PERSONAL CARE SERVICES (PCS) FOR LICENSED ADULT CARE HOME RESIDENTS
INDEPENDENT ASSESSMENT REQUEST FOR NE W ADMIS S IONS
Licensed Adult Care Home Provider: Use this form to report Medicaid beneficiaries admitted to your facility after CCME’s initial visit
to conduct independent eligibility assessments for the January 1, 2013 Consolidated PCS program. Report only Medicaid recipients
admitted to your facility who require a PCS eligibility assessment. Do not use this form if CCME’s initial visit to your facility is still in the
future.
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.
Receipt may be confirmed with CCME at 800-228-3365. E-mail questions to .
PLEASE COMPLETE ALL FIELDS.
Section A. Facility Information Complete all fields.
Today’s Date: ___/___/_______ (mm/dd/yyyy)
Facility Name:
Medicaid Provider Number _________________
Facility Contact Person:
Contact Position:
Facility Fax Number: (_____) _____ - ___________ Facility Phone: (_____) _____ - ___________ County:
Section B. New Admissions List each new admission on a separate line, and complete all fields.
Medicaid ID#
First Name
Last Name
Date of Birth
Admission Date
(mm/dd/yyyy)
(mm/dd/yyyy)
1.
________________________
__________________
__________________
___/___/_______
___/___/_______
2.
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3.
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4.
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5.
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6.
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7.
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8.
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9.
________________________
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10. ________________________
__________________
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11. ________________________
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12. ________________________
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13. ________________________
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14. ________________________
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15. ________________________
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16. ________________________
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17. ________________________
__________________
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18. ________________________
__________________
__________________
___/___/_______
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19. ________________________
__________________
__________________
___/___/_______
___/___/_______
20. ________________________
__________________
__________________
___/___/_______
___/___/_______
Attach additional sheet to report more than 20 New Admissions.
IMPORTANT:
Also initiate completion of the PCS Medical Attestation Form (DMA Form-3065) immediately for each New Admission
listed above. The required PCS Medical Attestation Form is available at
DMA-3066
11/14/2012
FORM NOT VALID FOR USE AFTER DECEMBER 31, 2012
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