Form Dma 3051 - Request For Independent Assessment For Personal Care Services (Pcs) Attestation Of Medical Need - North Carolina Department Of Health And Human Services
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North Carolina Department of Health and Human Services - Division of Medical Assistance
REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES (PCS)
ATTESTATION OF MEDICAL NEED
PCS is a Medicaid benefit based on an unmet need for assistance with Activities of Daily Living (ADLs), which
means bathing, dressing, toileting, eating, and mobility in the setting of care.
Completed form should be faxed to Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll free).
For the Expedited Assessment Process contact Liberty Healthcare Corporation at 1-855-740-1400.
For questions, call 855-740-1400 or 919-322-5944 or send an email to .
New Request
Change of Status: Medical
Please select one:
Date of Request: ___/___/___
Step
1
SECTION A. BENEFICIARY DEMOGRAPHICS
Step
2
Beneficiary’s Name: First:_____________________ MI:___ Last:______________________ DOB: ____/____/________
Medicaid ID#: __________________ PASRR#(For ACHs Only): ____________________ PASRR Date: ___/___/______
Gender: M F
Language: English Spanish Other_______________
Address:
_____ City: __________________________
County:
Zip:
Phone: _______________________
Alternate Contact (Non-PCS Provider)/Parent/Guardian
: Name: ____________________________
(required if beneficiary < 18)
Phone: _______________________________
Relationship to Beneficiary:
_____
Active Adult Protective Services Case? Yes No
Beneficiary currently resides: At home Adult Care Home Hospitalized/medical facility Skilled Nursing Facility
Group Home Special Care Unit (SCU) Other _________________ D/C date (Hospital/SNF) : ___/___/___
SECTION B. BENEFICIARY’S CONDITIONS THAT RESULT IN NEED FOR ASSISTANCE WITH ADLS
Step
3
Identify the current medical diagnoses related to the beneficiary’s need for assistance with qualifying Activities of Daily
Living (bathing, dressing, mobility, toileting, and eating). List both the diagnosis and the ICD-10 code for each.
ICD-10 Code
Date of Onset
Medical Diagnosis
Impacts ADLs
(Complete Codes Only)
(mm/yyyy)
Yes
No
_ _ _ . _ _ _ _
Yes
No
_ _ _ . _ _ _ _
Yes
No
_ _ _ . _ _ _ _
Yes
No
_ _ _ . _ _ _ _
Yes
No
_ _ _ . _ _ _ _
Short Term (3 Months)
Intermediate (6 Months)
In your clinical judgment, the ADL limitations are:
Expected to resolve or improve (with or without treatment)
Chronic and stable
Age Appropriate
Is Beneficiary Medically Stable? Yes No
Is 24-hour caregiver availability required to ensure beneficiary’s safety? Yes No
Optional
OPTIONAL ATTESTATION: P r a c t i t i o n e r s h o u l d r e v i e w t h e f o l l o w i n g a n d i n i t i a l o n l y i f a p p l i c a b l e :
Step 4
The beneficiary requires an increased level of supervision.
Initial if Yes: ________
The beneficiary requires caregivers with training or experience in caring for individuals who have a degenerative
disease, characterized by irreversible memory dysfunction, that attacks the brain and results in impaired memory, thinking,
and behavior, including gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning,
and the loss of language skills.
Initial if Yes: ________
Regardless of setting, the beneficiary requires a physical environment that includes modifications and safety
measures to safeguard the beneficiary because of the beneficiary's gradual memory loss, impaired judgment, disorientation,
personality change, difficulty in learning, and the loss of language skills.
Initial if Yes: ________
The beneficiary has a history of safety concerns related to inappropriate wandering, ingestion, aggressive behavior, and
an increased incidence of falls.
Initial if Yes: ________
DMA 3051
Page 1 of 3
10/1/2015
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