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.
ICD-10 Code
(Complete Codes Only)
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:
