NC Medicaid-3051 8/2018
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North Carolina Department of Health and Human Services NC Medicaid
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: / /
Medicaid ID#: PASRR#(For ACHs Only): PASRR Date:
/ /
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:
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 ICD-10 code for each.
Medical Diagnosis
ICD-10 Code
(Complete Codes Only)
Impacts ADLs
Date of Onset
(mm/yyyy)
_ _ _ . _ _ _ _

No
_ _ _ . _ _ _ _

No
_ _ _ . _ _ _ _

No
_ _ _ . _ _ _ _

No
_ _ _ . _ _ _ _

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, disorientation, personality change, difficulty in learning,
and 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 beneficiary because of the beneficiary's gradual memory loss, impaired judgment, disorientation,
personality change, difficulty in learning, and 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
2
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3
Optional
Step 4
NC Medicaid-3051 8/2018
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Beneficiary Name:
MID#:
-
PRACTITIONER FORM ENDS HERE
-
This Space Intentionally Left Blank
Sign
Here
Step 5
Attesting Practitioner’s Name: Practitioner NPI#:
Select one:

Beneficiary’s Primary Care Practitioner

Outpatient Specialty Practitioner

Inpatient Practitioner
Practice
Name:
Practice Stamp:
Practice NPI#:__________________________________________________
Practice Contact Name:
Address: _________________________________
Phone ( ) Fax ( )
Date of last visit to Practitioner:
/ /
**
Note:
Must be < 90 days from request 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 belief. 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 C. PRACTITIONER INFORMATION
Change of
Status
-
Medical
Describe the specific medical change in condition and its impact on the beneficiary’s need for hands on assistance (required
for all reasons):
SECTION D. CHANGE OF STATUS: MEDICAL
Complete for medical change of status request only.
NC Medicaid-3051 8/2018
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Beneficiary Name:
MID#:
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 F. CHANGE OF PCS PROVIDER
Requested By (select one):  Care Facility  Beneficiary  Other (Relationship to Beneficiary):
Requestor Contact’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
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):

Beneficiary

PCS Provider
Requested By
(select one):
SECTION E. CHANGE OF STATUS: NON-MEDICAL
Step
1
Step
2