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*If beneficiary does not have a PCP, the practitioner providing care and treatment for the medical, physical or cognitive condition
causing the functional limitation may complete the form.
N.C. Department of Health and Human Services – Division of Medical Assistance
REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES (PCS)
ATTESTATION OF MEDICAL NEED
INSTRUCTIONS
PCS is a Medicaid benefit based on the need for assistance with Activities of Daily Living (ADLs), which means bathing,
dressing, toileting, eating, and transferring/functional mobility in the home.
Page 1 and 2 shall be completed by the beneficiary’s primary care practitioner* or the inpatient practitioner,
and the beneficiary must have been seen by their PCP within the past 90 days.
Form must be completed by PCP for new requests and Changes of Status – Medical. Select the
appropriate box for the reason you are completing the form and include the date of the request.
Please complete the beneficiary’s demographic information in Section A, including where the
beneficiary currently resides. The beneficiary’s name should be the same as appears on their
Medicaid card. If the beneficiary currently resides in or is seeking admission into an Adult Care
Home, the facility’s information should be used as the beneficiaries address and phone number.
The Alternate Contact should not be a PCS Provider.
Section B contains the information about the beneficiary’s medical conditions that currently limit
his/her ability to perform ADLs independently. The medical diagnosis and the complete ICD-10
code related to the ADL deficit are required for processing.
For the Optional Attestation (see form), initial only if the beneficiary meets the requirement.
Please complete the practitioner and practice information in Section C. You may use the
practice stamp if applicable. Sign and date once completed. Signature stamps are not allowed.
If applicable, please describe the change in condition and how it impacts their need for
assistance.
PRACTITIONERFORMENDSHERE
FORNON‐MEDICALCHANGEOFSTATUSORCHANGEOFPROVIDERREQUESTS,COMPLETEPAGE3ONLY.
This page may be completed by the beneficiary, beneficiary’s family, or legally responsible person; home care
provider; or residential provider.
Select the appropriate box for the reason you are completing the form and include the date of the
request.
Please complete the beneficiary’s demographic information, including where the beneficiary
currently resides. The beneficiary’s name should be the same as it appears on their Medicaid card.
The Alternate Contact should not be a PCS Provider.
Complete the appropriate section for the requested change; Change of Status: Non-Medical
(Section E) or Change of Provider (Section F).
Completed form should be faxed to Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll
free). For the Expedited Assessment Process or questions, call 855-740-1400 or 919-322-5944.
Step1
Step2
Step3
Step5
Changeof
Status–
Medical
Step1
Step3
Opt.
Step4
Step2
DMA 3051
10/1/2015
Page 1 of 3
North Carolina Department of Health and Human Services - Division of Medical Assistance
REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES (PCS)
ATTESTATION OF MEDICAL NEED
PCS is a Medicaid benefit based on an unmet need for assistance with Activities of Daily Living (ADLs), which
means bathing, dressing, toileting, eating, and mobility in the setting of care.
Completed form should be faxed to Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll free).
For the Expedited Assessment Process contact Liberty Healthcare Corporation at 1-855-740-1400.
For questions, call 855-740-1400 or 919-322-5944 or send an email to NC-IAsupport@libertyhealth.com.
Please select one: New Request Change of Status: Medical Date of Request: ___/___/___
SECTION A. BENEFICIARY DEMOGRAPHICS
Beneficiary
’s Name: First:_____________________ MI:___ Last:______________________ DOB: ____/____/____
____
M
edicaid ID#: __________________ PASRR#(For ACHs Only): ____________________ PASRR Date:
___/___/____
__
Gender:
M
F Language:
English
Spanish
Other_______________
A
ddress: _____ City: __________________________
C
ounty: Zip: Phone: _______________________
A
lternate Contact (Non-PCS Provider)/Parent/Guardian (required if beneficiary < 18): Name: ________________________
____
Re
lationship to Beneficiary: _____ 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 D
aily
Living
(bathing, dressing, mobility, toileting, and eating). List both the diagnosis and the ICD-10 code for each.
Medical Diagnosis
ICD-10 Code
(Complete Codes Only)
Impacts ADLs
_ _ _ . _ _ _ _
Yes No
_ _ _ . _ _ _ _
Yes No
_ _ _ . _ _ _ _
Yes No
_ _ _ . _ _ _ _
Yes No
_ _ _ . _ _ _ _
Yes No
In your clinical judgment, the ADL limitations are:
Short Term (3 Months) Intermediate (6 Months)
Expected to resolve or improve (with or without treatment) Chronic and stable Age Appropriate
Is Beneficiary Medically Stable?
Yes No
Is
24-hour caregiver availability required to ensure beneficiary’s safety? Yes No
OPTIONAL ATTESTATION
: Practitioner should review the following and initial only if applicable
:
The
beneficiary requires an increased level of supervision. Initial if Yes: ________
The
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, disorie
ntation, personality change, difficulty in learning,
a
nd the loss of language skills. Initial if Yes: ________
Regardless of setting, the
beneficiary requires a physical environment that includes modifications and safety
measures
to safeguard the benefi
ciary because of the beneficiary's gradual memory loss, impaired judgment, disorientation,
personality change, difficulty in learning, a
nd the loss of language skills. Initial if Yes: ________
The
beneficiary has a history of safety concerns
related to inappropriate wandering, ingestion, aggressive behavior, and
an increased incidence of falls.
Initial if Yes: ________
Step
1
Step
3
Step
2
Optional
Step 4
Print Form
Beneficiary Name: ________________________________________ MID#:_______________________
DMA 3051
10/1/2015
Page 2 of 3
SECTION C. PRACTITIONER INFORMATION
Attesting
Practitioner’s Name: _____________________________________ Practitioner NPI#:
___________________
Select one
: Beneficiary’s Primary Care Practitioner Outpatient Specialty Practitioner Inpatient Practitioner
P
ractice Name: _________________________________________________
Practice
NPI#:__________________________________________________
Practice
Contact Name: ___________________________________________
Address
:_______________________________________________________
P
hone (______) _______________ Fax (______) _________________
Dat
e of last visit to Practitioner : ____/____/____ **Note: Must be < 90 days from request date
__________________________________________ 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 belief. I understand that my attestation may result in the provision of services which are paid for
by state and federa
l 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
for all reasons):
- PRACTITIONER FORM ENDS HERE -
This Space Intentionally Left Blank
Sign
Here
Practice Stamp:
Step 5
Practitioner Signature AND Credentials:
Date:
Change of
Status -
Medical
Beneficiary Name: ________________________________________ MID#:_______________________
DMA 3051
10/1/2015
Page 3 of 3
FOR NON-MEDICAL CHANGE OF STATUS OR CHANGE OF PROVIDER REQUESTS, COMPLETE THIS PAGE ONLY.
Please select one: Change of Status: Non-Medical Change of PCS Provider Date of Request:___/___/___
Beneficiary’s Name: First:_____________________ MI:___ Last:______________________ DOB: ____/____/________
Medicaid ID#: _______________
Gender:
M
F Language:
English
Spanish
Other __________________
Address: _____ City: ____________________________________
County: ______________ Zip: _ Phone: ________________________________
Alternate Contact (Non-PCS Provider)/Parent/Guardian (required if beneficiary < 18): Name:__________________________
Relationship to Beneficiary: ________ 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
Responsible Party
: Guardian Legal Power Of Attorney (POA) Family (Relationship):
________________
Requestor
Name: ______________________________________
______________________________________________
PCS Provider NPI#: ______________________________
PCS Provider Locator Code#: _______________
(three digit code)
Facility License #
(if applicable): ______________________ License Date (if applicable): ____________________
(mm/dd/yyyy)
Provider Contact Name: _______________________________________ Contact’s Position: ________________________
Provider
Phone_______________________________________ Provider Fax:
___________________________________
Email: __________________________________________________
_________________________
__________________
Reason for Change in Condition Requiring Reassessment:
Change in beneficiary’s location affecting ability to perform ADLs
Change in caregiver status
Change in days of need
Other: ________________________________________________________________
Describe the specific change in condition and its impact on the
beneficiary
’s need for hands on assistance (required for all
reasons):
SECTION F. CHANGE OF PCS PROVIDER
Requested By
(select one): Care Facility Beneficiary Other (Relationship to Beneficiary)
: ___________________
Requestor C
ontact’s Name: ______________________________________ Phone: ______________________
_______
Reason for Provider Change
(select one):
Beneficiary or legal representative’s choice
Current provider unable to continuing providing services
Other:_____________________________________________________________________________________
Status of PCS Services
(select one):
Discharged/Transferred on ___________________________(mm/dd/yyyy)
Scheduled for discharge/transfer on ___________________________(mm/dd/yyyy)
Continue receiving services until beneficiary is established with a new provider agency; no
discharge/transfer is
planned
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: _____________
_______________
PCS
Provider NPI#: _____________________________ PCS Provider Locator Code#: _________________(3
digit code)
Facility License #
(if applicable): _____________________ License Date (if applicable): _____________________(mm/dd/yyyy)
Physical Address: ___________________________________________________________________________________
Change of
Provi
der
Change of
Status:
Non-
Medical
Step
1
Step
2
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Completed 16 April 2022

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