Form Dma 3051 - Request For Independent Assessment For Personal Care Services (Pcs) Attestation Of Medical Need - North Carolina Department Of Health And Human Services Page 2

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Beneficiary Name: ________________________________________
MID#:_______________________
SECTION C. PRACTITIONER INFORMATION
Step 5
Attesting Practitioner’s Name: _____________________________________ Practitioner NPI#:___________________
Select one:  Beneficiary’s Primary Care Practitioner  Outpatient Specialty Practitioner  Inpatient Practitioner
Practice Stamp:
Practice Name: _________________________________________________
Practice NPI#:__________________________________________________
Practice Contact Name: ___________________________________________
Address:_______________________________________________________
Phone (______) _______________ Fax (______) _________________
**
Date of last visit to Practitioner : ____/____/____
Note: Must be < 90 days from request date
Sign
Practitioner Signature AND Credentials:
Date:
__________________________________________ Date: ____/____/____
Here
*Signature stamp not allowed*
“I hereby attest that the information contained herein is current, complete, and accurate to the best of my
knowledge and belief. I understand that my attestation may result in the provision of services which are paid for
by state and federal funds and I also understand that whoever knowingly and willfully makes or causes to be
made a false statement or representation may be prosecuted under the applicable federal and state laws.”
Change of
SECTION D. CHANGE OF STATUS: MEDICAL
Status -
Complete for medical change of status request only.
Medical
Describe the specific medical change in condition and its impact on the beneficiary’s need for hands on assistance (required
for all reasons):
- PRACTITIONER FORM ENDS HERE -
This Space Intentionally Left Blank
DMA 3051
Page 2 of 3
10/1/2015

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