Personal Care Assistance (Pca) Technical Change Request Form - Minnesota Health Care Programs (Mhcp) - Minnesota Department Of Human Services Page 2

Download a blank fillable Personal Care Assistance (Pca) Technical Change Request Form - Minnesota Health Care Programs (Mhcp) - Minnesota Department Of Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Personal Care Assistance (Pca) Technical Change Request Form - Minnesota Health Care Programs (Mhcp) - Minnesota Department Of Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Personal Care Assistance (PCA)
Technical Change Request
Purpose of PCA Technical Change
Recipient Information
Request
Enter complete legal name
„
Enter the 8 digit Subscriber ID number (also known
To request technical changes and corrections to
„
as MA number and recipient ID)
existing SAs for some Personal Care Assistance
Select PCA Traditional or PCA Choice
„
(PCA) services.
Enter the date of birth
„
Eligibility
Provider Agency Information
Verify MA eligibility using MN–ITS or call
Enter the PCA Agency name
651‑431‑4399 or 800‑657‑3613.
„
Enter PCA Agency NPI/UMPI
„
Third Party Payers
Enter name and title of the person submitting
„
MA is the payer of last resort. Information regarding
the request
other payers is available through EVS.
Enter the PCA Agency phone number
„
Form Instructions
Enter the PCA Agency fax number
„
Request Type
Additional Information
Select the type of change or correction you are
Enter additional information regarding the request.
requesting. Refer to Authorization Requirements
Recipient/Responsible Party Signatures
in the PCA section of the MHCP Provider Manual
Required when “New Provider” request type.
for additional information.
Enter the Change/Start and End Dates.
ADA1 (12-12)
This information is available in accessible formats for individuals with disabilities by calling
651‑431‑2670, toll‑free 800‑657‑3739, or by using your preferred relay service. For other
information on disability rights and protections, contact the agency’s ADA coordinator.
651‑431‑2670 or 1‑800‑657‑3739
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному
выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Change Report Form - Minnesota Department Of Human Services Change Report Form - Minnesota Department Of Human Services Legal
Minnesota Department Of Human Services 90 Day Transition Plan For Youth Discharged After Age 18 Minnesota Department Of Human Services 90 Day Transition Plan For Youth Discharged After Age 18 Business
Minnesota Department Of Human Services Application For Family Child Minnesota Department Of Human Services Application For Family Child Legal
Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Legal
Adoption Assistance Agreement - Minnesota Department Of Human Services Adoption Assistance Agreement - Minnesota Department Of Human Services Legal
Child Foster Care Home Safety Checklist - Department Of Human Services Child Foster Care Home Safety Checklist - Department Of Human Services Legal
Form Il444-3455 - Child Care Application - Department Of Human Services - Bureau Of Child Care And Development Form Il444-3455 - Child Care Application - Department Of Human Services - Bureau Of Child Care And Development Legal
Form Il444-3455e - Child Care Redetermination - Department Of Human Services - Bureau Of Child Care And Development Form Il444-3455e - Child Care Redetermination - Department Of Human Services - Bureau Of Child Care And Development Legal
Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services Legal
Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2