Fillable DMA-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE (North Carolina)

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DMA-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE (North Carolina)

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Alternate Contact (Select One): Parent
Relationship to Beneficiary (NON-PCS Provider):
Name:
MI: Last:
RSID#(ACH Only):
Beneficiary Name:
MID#:
1
DMA-3051
5/10/19
DMA-3051
REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES (PCS)
ATTESTATION OF MEDICAL NEED
MEDICAL CHANGE OF STATUS OR NEW REQUESTS, PRACTITIONERS COMPLETE PAGES 1 & 2 ONLY
REQUEST TYPE:
(select one)
DATE OF REQUEST:
Change of Status: Medical
New Request
/ /
Form Submission:
Fax Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll free).
Expedited Assessment Process Info:
Contact Liberty Healthcare Corporation at 1-855-740-1400.
Questions:
Call Liberty Healthcare at 855-740-1400 or 919-322-5944.
SECTION A. BENEFICIARY DEMOGRAPHICS
Beneficiary’s Name: First: DOB: / /
Medicaid ID#: RSID Date:
/ /
Gender:
Male
Female Language:
English
Spanish
Other
Address: _ _ City: _
County: Zip: _ Phone:
( )
Legal Guardian (required if beneficiary < 18) Other
_ Phone: ( )
Active Adult Protective Services Case? Yes No
Beneficiary currently resides:
At home
Adult Care Home
Hospitalized/medical facility
Skilled Nursing Facility
Group Home
Special Care Unit (SCU)
Other D/C Date (Hospital/SNF): / /
SECTION B. BENEFICIARY’S CONDITIONS THAT RESULT IN NEED FOR ASSISTANCE WITH ADLS
Identify the current
medical diagnoses related to the beneficiary’s need for assistance with
qualifying Activities of Daily Living
(bathing, dressing, mobility, toileting, and eating). List both the diagnosis and the COMPLETE ICD-10 Code.
Medical Diagnosis
ICD-10
Code
Impacts
ADLs
Date of Onset
(mm/yyyy)
1.
_ _ _ . _ _ _ _
Yes
No
2.
_ _ _ . _ _ _ _
Yes
No
3.
_ _ _ . _ _ _ _
Yes
No
4.
_ _ _ . _ _ _ _
Yes
No
5.
_ _ _ . _ _ _ _
Yes
No
6.
_ _ _ . _ _ _ _
Yes
No
7.
_ _ _ . _ _ _ _
Yes
No
8.
_ _ _ . _ _ _ _
Yes
No
9.
_ _ _ . _ _ _ _
Yes
No
10.
_ _ _ . _ _ _ _
Yes
No
In your clinical judgment, ADL limitations are:
Short Term (3 Months)
Intermediate (6 Months)
Age Appropriate
Expected to resolve or improve (with or without treatment) Chronic and stable
Is Beneficiary Medically Stable?
Yes No
Is 24-hour caregiver availability required to ensure beneficiary’s safety?
Yes No
Beneficiary Name:
MID#:
2 DMA-3051
5/10/2019
OPTIONAL ATTESTATION
:
Practitioner should review the following and initial only if applicable:
Beneficiary requires an increased level of supervision.
Beneficiary requires caregivers with training or experience
in caring for individuals who have a
degenerative disease, characterized by irreversible memory dysfunction, that attacks the brain and results in
impaired memory, thinking, and behavior, including gradual memory loss, impaired judgment, disorientation,
personality change, difficulty in learning, and the loss of language skills.
Beneficiary requires a physical environment, regardless of setting, that includes modifications and
measures
to safeguard the beneficiary because of the beneficiary's gradual memory loss, impaired judgment,
disorientation, personality change, difficulty in learning, and the loss of language skills.
Beneficiary has a history of safety concerns
related to inappropriate wandering, ingestion, aggressive
behavior, and an increased incidence of falls.
Initial: _______
Initial: _______
Initial: _______
Initial: _______
SECTION C. PRACTITIONER INFORMATION
Attesting Practitioner’s Name: _Practitioner NPI#:
Select one: Beneficiary’s Primary Care Practitioner Outpatient Specialty Practitioner Inpatient Practitioner
Practice Name: _ NPI#:
Practice Stamp
Practice Contact Name:
Address: _
Phone: ( ) _ Fax: ( )
Date of last visit to Practitioner:
/ /
**
Note:
Must be < 90 days from Received Date
Practitioner Signature AND Credentials: Date:
/ /
*Signature stamp not allowed*
“I hereby attest that the information contained herein is current, complete, and accurate to the best of my knowledge and bel
ief. 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.”
SECTION D. CHANGE OF STATUS: MEDICAL Complete for medical change of status request only.
Describe the specific medical change in condition and its impact on the beneficiary’s need for hands on assistance (Required):
--- PRACTITIONER FORM ENDS HERE ---
Beneficiary Name:
MID#:
3 DMA-3051
5/10/2019
NON
--
‐
MEDICAL CHANGE OF STATUS OR CHANGE OF PROVIDER REQUESTS, COMPLETE PAGE 3 ONLY
REQUEST TYPE:
(select one)
DATE OF REQUEST:
Change of Status: Non-Medical
Change of Provider
/ /
Form Submission:
Fax Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll free).
Questions:
Call Liberty Healthcare at 855-740-1400 or 919-322-5944.
BENEFICIARY DEMOGRAPHICS
Beneficiary’s Name: First: MI: Last: DOB: / /
Medicaid ID#:
Gender:
Male
Female Language:
English
Spanish
Address: _ City:
Other
County: Zip: _ Phone:
( )
Alternate Contact (Select One): Parent Legal Guardian (required if beneficiary < 18) Other
Relationship to Beneficiary (NON-PCS Provider):
Name: _ Phone: ( )
Beneficiary currently resides:
At home
Adult Care Home
Hospitalized/medical facility
Skilled Nursing Facility
Group Home
Special Care Unit (SCU)
Other D/C Date (Hospital/SNF): / /
SECTION E: CHANGE OF STATUS: NON-MEDICAL
Requested by
(Select One):
PCS
Provider
Beneficiary
Legal
Guardian
Power of
Attorney (POA)
Responsible
Party
Family (Relationship):
___________________
Requestor Name
:
PCS Provider NPI#:
PCS Provider Locator Code#: ___ ___ ___
Facility License # (if applicable):
Date:
/ /
Contact’s Name: ___________________________________ Contact’s Position: _____________________________________
Provider Phone: ( ) Provider Fax: ( ) Email:
Reason for Change in Condition Requiring Reassessment
(Select One):
Change in Days of Need Change in Caregiver Status Change in Beneficiary location affects
Other: _ ability to perform ADLs
Describe the specific change in condition and its impact on the beneficiary’s need for hands on assistance (Required):
SECTION F: CHANGE OF PCS PROVIDER
Requested by
(Select One):
Care Facility
Beneficiary
Other (Relationship): __________________________
Requestor’s Contact
Name: Phone: ( )
Reason for Provider Change
(Select One):
Beneficiary or legal
representative’s choice
Current provider unable to
continue providing services
Other
:
_______________
Status of PCS Services
(Select One):
Discharged/Transferred Scheduled Discharge/Transfer
No Discharge/Transfer Planned.
Date: / / Date: / / Continue receiving services until established with a new provider.
BENEFICIARY’S PREFERRED PROVIDER
(Select One):
Home Care
Agency
Family Care
Home
Adult Care
Home
Adult Care Bed in Nursing
Facility
SLF-
5600a
SLF-
5600c
Special Care
Unit
Agency Name:
Phone: ( )
Provider NPI#:
Provider Locator Code#: ___ ___ ___
Facility License # (if applicable):
Date:
/ /
Physical Address:
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DMA-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE (North Carolina)

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Completed 16 April 2022

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