Personal Care Assistance (Pca) Technical Change Request Form - Minnesota Health Care Programs (Mhcp) - Minnesota Department Of Human Services

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Clear Form
*DHS-4074A-ENG*
DHS-4074A-ENG
7-12
Minnesota Health Care Programs (MHCP)
Personal Care Assistance (PCA) Technical
Change Request
Complete and fax this form to 651‑431‑7447 to request a technical change to an existing approved PCA service authorization
(SA) for your agency. Complete and fax the
Referral for PCA Services
to the PHN to request a new authorization or report a
change in condition.
Request Type
Change/Start Date
__ __ / __ __ / __ __ __ __
End Date
__ __ / __ __ / __ __ __ __
(request for your agency only)
Provider Change
:
(select one)
New provider
(requires Recipient/Responsible party signature below)
Discontinuing provider – Total number of units to release
___________
Other
:
(Explain in the additional information section)
Report change in Responsible Party
Reprocess SA
due to update in eligibility or living arrangement
__ __ __ __ __ __ __ __ __ __ __
Partial Release of Units due to multiple providers
Reconsideration
Reinstate as enrollment record update
__ __ __ __ __ __ __ __ __ __ __
Duplicate copy of SA
__ __ __ __ __ __ __ __ __ __ __
Health Plan Disenrollment (PMAP lapse). Diagnosis:
__________ __________ __________
(Attach a copy of the MCO authorization)
.
.
.
Recipient Information
LAST NAME
FIRST NAME
MI
SUBSCRIBER ID
DATE OF BIRTH
__ __ / __ __ / __ __ __ __
__ __ __ __ __ __ __ __
PCA Traditional
PCA Choice
Provider Agency Information
AGENCY NAME
AGENCY NPI/UMPI
__ __ __ __ __ __ __ __ __ __
NAME/TITLE OF REQUESTOR
PHONE NUMBER
FAX NUMBER
Additional Information
Recipient/Responsible Party
– Required only when “New Provider” change requested
NAME (please print)
RELATIONSHIP TO RECIPIENT
DATE CHANGE IS REQUESTED
DATE CURRENT PROVIDER WAS NOTIFIED
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
SIGNATURE OF RECIPIENT/RESPONSIBLE PARTY
DATE
__ __ / __ __ / __ __ __ __

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