Hscsn Personal Care Aide Referral Form

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HSCSN Personal Care Aide (PCA) Referral Form
Please complete the information and fax to HSCSN at 202-721-7190
I. MEMBER INFORMATION
Member Name:
Sex:
M
F
Ht
Wt
Member ID:
Date of Birth:
Primary Diagnosis :
Treating Diagnosis/ICD 9 Code for Home Care:
II. OTHER PERTINENT CLINICAL INFORMATION
III. REQUESTING PROVIDER INFORMATION (MD or NP): Please Print
Provider Name
Phone
Address
City
State
ZIP
Provider Signature
Date
IV. REASON FOR REFERRAL
HSCSN requires an initial and periodic assessment of the enrollee by a Home Health RN to determine personal care
aide needs in the home. Based on Medicaid regulations and medical necessity requirements, the enrollee must have a
documented need for home care; services cannot be authorized for convenience or babysitting.
Upon receipt and review of the completed Home Health RN assessment, the HSCSN Home Health nursing staff will
send the RN assessment to the treating provider with an order indicating the level of care, number of hours and schedule,
as determined by the assessment. The treating provider will review, sign and date the order with modifications as
needed.
Indicate the service(s) being requested:
Personal Care Aide (PCA)- services not related to a behavioral health condition
 
provided by non-licensed staff to
assist with basic personal care services, includingbathing, grooming, toileting, feeding, and mobility If enrollee requires
assistance related to his/her behavioral health needs please complete the BH Home Services Form.
Comments:_____________________________________________________________________________
Occupational Therapy
Physical Therapy
Speech Therapy
Social Work
Comments:_____________________________________________________________________________
This referral form does not guarantee approval for PCA services. The Physician will be sent the outcome of the
RN assessment and recommendations by fax, within 72 hours of completion of the assessment. Please contact the
HSCSN UM Department 202-467-2737 if you have any questions about the referral or form.

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