Personal Care Services Request For Services Form
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N.C. Department of Health and Human Services – Division of Medical Assistance
PERSONAL CARE SERVICES (PCS) REQUEST FOR SERVICES FORM
Completed form should be sent to Liberty Healthcare Corporation-NC via fax at 484-434-1571 or 855-740-1600 (toll free) or mail: ATTN: Liberty
Healthcare Corporation, PCS Program 5540 Centerview Dr. Suite 114, Raleigh, NC 27606-3386. For questions, contact 855-740-1400 or 919-322-5944
or send an email to . DISCLAIMER: Adherence to the INSTRUCTIONS for the Request for Services Form is
REQUIRED. If a request for services form is submitted incomplete, an unable to process notification will be issued and a new request for
services form will be required. For the Expedited Assessment Process contact Liberty Healthcare Corporation at 1-855-740-1400
PROVIDER TYPE (select one)
DATE OF REQUEST:
(mm/dd/yyyy)
Home Care Agency
Family Care Home
Adult Care Home
Adult Care Bed in Nursing Facility
SLF-5600a
SLF-5600c
Special Care Unit (stand-alone Special Care Unit or SCU bed)
SECTION A. RECIPIENT DEMOGRAPHICS
Medicaid ID#:
Recipient’s Name (as shown on Medicaid Card) First:_______________________________ MI:____ Last:______________________________
Date of Birth:
(mm/dd/yyyy)
Gender:
Male
Female
Primary Language:
English
Spanish
Other
Address:
City: __________________________________________
County:
Zip:
(zip code + 4 digit extension) Phone: ________________________________
Alternate Contact/Parent/Guardian (required if patient under 18): First:______________________________ Last: _______________________
Phone: _____________________________________
Relationship to Patient:
Provider Name (if applicable)
Provider Phone:______________________________
SECTION B. RECIPIENT’S MEDICAL HISTORY – complete this section only if submitting a NEW REFERRAL or CHANGE OF
STATUS request.
List both the current medical diagnoses and ICD-9 codes that currently limit patient’s ability to independently perform Activities of Daily Living
(bathing, dressing, mobility, toileting, and eating), prepare meals, and manage medications.
Enter “O” for Onset or
Medical Diagnosis
ICD-9 Code
Date (mm/yyyy)
“E” for Exacerbation
SECTION C. NEW REFERRAL REQUEST – complete this section if submitting a New Referral.
Check the box to the left and complete sections A, B, and C if submitting a New referral.
Referral Entity
Primary Care Physician
Attending MD
Physician Assistant
Nurse Practitioner
(select one):
(PA)
(NP)
Is Recipient Medically Stable:
Is there an active Adult Protective Services (APS) case:
Yes
No
Yes
No
Date of last visit to Referring Entity: ___________________________
(mm/dd/yyyy)
Other state/federal programs recipient is currently receiving
(select all that apply):
Medicare Home Health
Private Duty Nurse
CAP
Hospice
Unknown
Is 24-hour caregiver availability required to ensure recipient’s safety?
Yes
No (e.g., Does patient have unscheduled ADL
needs or require safety supervision or structured living, or is patient unsafe if left alone for extended periods?)
Is recipient currently hospitalized or in a medical facility:
Yes
No
If yes, planned discharge date:
(mm/dd/yyyy)
Is recipient currently in a Skilled Nursing Facility (SNF):
Yes
No
if yes, planned discharge date: ____________(mm/dd/yyyy)
Referring Entity’s Name:
NPI#:
________________________________________________________________
_________________________
Practice Name:
______________________________________________________________________________________________(if applicable)
Name of Practice Point of Contact:
Position:
______________________________
Phone (including area code):
Fax (including area code):
_____________________________________
______________________________
Point of Contact’s Email Address:__
_____________________________________________________________________________________
Referring Entity/Practitioner Signature: ______________________________________________ Date: ___________
(mm/dd/yyyy)
NOTE: Dated signature is verification that the information in sections A, B, and C is accurate for this recipient and authorization to conduct a PCS
eligibility assessment. If requesting an assessment for greater than 80 hours of PCS completion of sections A, B, C, and E with a second signature
is REQUIRED on page 2. If not stop here and submit to Liberty.
DMA 3051
12/01/2013
Page 1 of 3
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