Fillable Pca-no Change (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Pca-no Change (Commonwealth of Massachusetts) Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Pca-no Change (Commonwealth of Massachusetts)

On average this form takes 14 minutes to complete

The Pca-no Change (Commonwealth of Massachusetts) form is 2 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 55 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PCA-R (Rev. 10/10)
Personal care management (PCM) agencies may use this reevaluation form when submitting a request for personal care attendant (PCA)
services where the prior authorization (PA) is due to expire, and the PA request is for the same number of PCA hours per week and per night
that MassHealth had authorized at the start date of the current prior authorization. PCM agencies must submit the MassHealth Evaluation
for Personal Care Attendant Services form (PCA-2) when the number of PCA hours being requested per week or per night are greater or less
than the number of PCA hours MassHealth authorized at the start date of the current PA.
Note: All PCA reevaluations must be submitted at least 21 days before the expiration date of the PA to ensure no interruption of PCA services.
SECTION I: Consumer Information
Consumer Name
MassHealth ID no: PCM agency name:
Date PA request submitted to MassHealth:
Current PA no: Current PA expiration date:
Number of day/evening PCA hours authorized per week
Number of night PCA hours authorized per night
at start date of the current PA: at start date of the current PA:
Was the current PA authorized for two or more years? . . . . . . . . . . . . . . . . . . . . . .
Yes No
Was there an adjustment in PCA hours since the start of the PA?: . . . . . . . . . . . . . . .
Yes No
If
yes, please complete and submit the
MassHealth Evaluation for Personal Care Attendant Services
form (PCA-2).
SECTION II: Surrogate Assessment
A. I have conducted an assessment of the consumer’s ability to independently manage the PCA program, in accordance with 130 CMR 422.222(A), and
have determined that (Check one below.):
The consumer appears to have the necessary cognitive and emotional ability and skills to perform all of the tasks of managing PCA services
and does not require a surrogate. (Complete C only.)
The consumer does not have the necessary cognitive or emotional ability and skills to perform some or all of the tasks of managing PCA
services and requires a surrogate. (Complete B and C below.)
B. Surrogate name, address, and phone number:
Surrogate’s relationship to consumer:
C. Name of PCM agency sta member who conducted the assessment:
Title: Date of assessment:
SECTION III: RN Evaluation and Signature
Note: The PCM agency registered nurse (RN) is required to conduct a full evaluation of the consumer’s need for medically necessary PCA
services, in the presence of the consumer, before the expiration of the current PA. This evaluation must be performed for each consumer even
if it is determined that there is no change in the consumer’s PCA services.
I, (PCM RN name) , have conducted a full evaluation of the consumer’s need for medically necessary
PCA services on (date)
. The evaluation was conducted in the presence of the consumer in one of the following locations:
home nursing facility hospital other (describe):
Personal Care Attendant
Reevaluation Form (No Change)
Consumer Name:
T H E C O M M O N W E A LT H O F M A S S A C H U S E T T S
Executive Office of Health and Human Services
Use this form when there is no change in PCA hours.
Print
Reset
Based on my evaluation, I have determined that the consumer is managing well with the PCA hours authorized at the start date of the current PA, and
requires the same number of hours per week or per night of physical assistance with activities of daily living (ADLs) and instrumental activities of daily
living (IADLs) that MassHealth authorized at the start of the PA identified in Section I above. I have reviewed and agree with the surrogate assessment
as stated in Section II above.
I am requesting:
hours of day/evening PCA services per week and
hours of night PCA services per night (midnight to 6:00 A.M.)
Beginning:
and ending:
RN additional comments/remarks:
RN signature: Signature date:
SECTION IV: Consumer or Legal Guardian Signature
I was reevaluated in person and the PCM agency has explained to me the number of PCA hours being requested for me per week or per night, and has
assessed my need for a surrogate as stated in Section II above. I understand that the PCM agency is requesting no change in the number of PCA hours.
Consumer signature:
Date:
Reason if unable to sign:
Legal guardian signature (required if consumer has a legal guardian):
Date:
Surrogate signature (as appropriate):
Date:
SECTION V: Physician or Nurse Practitioner Signo
Enclosed is (Check one.):
Documentation that the PCM agency’s RN has obtained verbal authorization from the member’s physician or nurse practitioner in accordance
with 130 CMR 422.416(A)(4)(b). The PCM agency must obtain physician or nurse practitioner sign o within 60 days after the request for prior
authorization is sent to MassHealth. (The physician or nurse practitioner signature is not required below at the time the PA request is submit-
ted to MassHealth, but the PCM agency must obtain the completed and signed physician or nurse practitioner sign o of Section VI below
within 60 calendar days of the date that the PA request is sent to MassHealth.)
Physician or nurse practitioner sign o (Physician or nurse practitioner must sign below.).
SECTION VI: Certification and Signature
I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to the best of my
knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of
any material fact contained herein.
The consumer requires hours per week of day/evening PCA services
The consumer requires hours per night of PCA services (Midnight to 6:00 A.M.)
Physician or nurse practitioner signature:
Date:
Printed name of physician or nurse practitioner:
Date:
Physician/nurse practitioner address:
Telephone number:
Consumer Name
Print
Reset
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Pca-no Change (Commonwealth of Massachusetts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document