Section 1: Additional Comments (to be filled out by PCM agency)
Additional comments (Attach additional sheets and supporting
documentation as necessary.):
I have reviewed this adjustment request:
in person/over the telephone (circle one)
I have reviewed this adjustment request with the consumer.
Review date: _____________
Signature of Requesting PCM Agency Reviewer Title Date
Section 2: Hours Requested (to be filled out by PCM agency)
Requesting an adjustment from (Check and complete all that apply.)
___________ hours to ___________ day/evening hours per week
___________ hours to ___________ day/evening hours per week
______________ (date) to ___________ (date)
A cover letter must include the reason for the adjustment request.
Specify what has changed for the consumer and how this change
impacts the need for physical assistance with ADLs or IADLs.
Section 3: Physician/Nurse Practitioner Signature/Comments
Section 3 must be completed by the consumer’s physician or
nurse practitioner in lieu of a letter of medical necessity from the
physician or nurse practitioner.
Requesting an adjustment from (Check and complete all that apply.)
___________ hours to ___________ day/evening hours per week
___________ hours to __________ hours per night
Physician or nurse practitioner comments (attach additional
sheets as necessary):
I have reviewed and agree with this request for an adjustment
in this consumer’s authorized number of hours of PCA services.
The adjustment is a result of changes in the consumer’s condition
and/or functional status or a change in living condition that affects
the consumer’s ability to perform ADLs/IADLs without physical
assistance.
Signature of Physician or Nurse Practitioner Date
Print physician or nurse practitioner name, address,
and telephone number:
PCA Prior Authorization Adjustment Form (cont.)
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