Dma 3000 Form – Fill Out and Use This PDF

The DMA-3000 form is a vital document, serving as a Physician Authorization for Certification and Treatment (PACT) specifically designed for patients requiring Personal Care Services (PCS). It encompasses comprehensive sections for annual certification, patient and provider information, detailed assessments on patient needs, and the plan of care. This form is instrumental for healthcare professionals in establishing a tailored care plan that addresses the unique needs of patients needing personal assistance. To ensure a seamless process in managing Personal Care Services for those in need, consider filling out the DMA-3000 form by clicking the button below.

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Dma 3000 Form PDF Details

Navigating the maze of healthcare paperwork can often feel overwhelming for patients and their families. Among the numerous forms that must be completed to ensure the provision of tailored healthcare services, the DMA-3000 form stands out for its critical role in the Personal Care Services (PCS) process. This form, titled "Physician Authorization for Certification and Treatment (PACT)," serves as an annual certification document essential for patients requiring personal care services under Medicaid. It encompasses a comprehensive assessment of a patient's current medical condition, including vital information such as personal and provider details, diagnosis, current care plans, and a meticulous appraisal of the patient's ability to perform Activities of Daily Living (ADLs). The form also dives deep into the patient's medical history and present condition, capturing vital signs, medications, limitations, and the need for assistance in everyday tasks. Moreover, it outlines the plan of care, establishing a clear pathway for the provision of necessary services, which are crucial for maintaining or improving the patient's quality of life. Additionally, the DMA-3000 form plays a vital role in ensuring that caregivers and healthcare providers adhere to Medicaid guidelines, providing a standardized method for assessing the necessity and extent of personal care services. By doing so, it not only helps in the efficient allocation of resources but also in safeguarding the well-being of individuals who rely on these essential services.

Question	Answer
Form Name	Dma 3000 Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	dma 3000, dma printable forms, get dma 3000, dma 3000 pact

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Annual Certification Due:__________

PERSONAL CARE SERVICES (PCS)

PHYSICIAN AUTHORIZATION FOR CERTIFICATION AND TREATMENT (PACT) FORM

Referral Date:

Date Initial Assessment Completed:

Date Last Reassessment Completed:

Provider Name:

PCS Provider #:

Provider Phone #:

Provider Address:

PATIENT INFORMATION

PATIENT FIRST & LAST NAME:

MEDICAID ID # (MID):

3. SOCIAL SECURITY#

PATIENT ADDRESS:

PATIENT PHONE:

6. SEX: Male

Female 7. DATE OF BIRTH (mm/dd/yy):

PATIENT LIVES: Check all that apply Alone

w/Spouse

w/Adult Child(ren)

w/Parent(s)

w/others

CONTACT PERSON’S NAME:

RELATIONSHIP TO PATIENT:

ADDRESS:

PHONE: (H)

(W)

10. ATTENDING PHYSICIAN’S NAME:

PHONE:

ADDRESS:

11. DATE OF MOST RECENT EXAM (mm/dd/yy):________

12. Vital Signs @ Assessment: B/P

T____ P____ R____ Wt____ Ht____

13. REASON FOR REFERRAL:

Referral Source:

14.

DIAGNOSIS (Specify date of onset and ICD-9 code):

______________________________________________________________________________________________________________________

15. CURRENT CARE (Type and Source):

ASSESSMENT

16.	LIST ALL MEDICATIONS BELOW: (Name/Dose/Frequency/Route)

17.	Self-Administered?	Yes No If no, who assists? (Name/Relationship)				Reminders needed? Yes	No

18.	Does the individual have any allergies?:		No Known Allergies	Yes	If yes, LIST ALL KNOWN ALLERGIES BELOW:

DMA-3000 Physician Authorization for Certification and Treatment (PACT) Form

Page 1 of 4

PATIENT FIRST & LAST NAME:	MEDICAID ID#:	ASSESSMENT DATE:

Limitations in Activities of Daily Living (ADLs)

Rate the individual’s ADL Self-Performance and ADL Support Provided using the scores below. Check the applicable boxes. Indicate the days when assistance is needed in the blank beside

a task.

M=Mon T=Tues

W=Wed

Th=Thurs

F=Fri

S=Sat

Sun=Sunday

A. ADL Self-Performance Scores

INDEPENDENT: No help needed or oversight needed.

Place a check in the box if assistance is needed

SUPERVISION: Oversight, encouragement, or cueing needed.

A. ADL Self-Performance

B. ADL Support Provided

LIMITED ASSISTANCE: Individual highly involved in activity; receives hands-on help in guided maneuvering of limbs with eating, toileting, bathing,

dressing, personal hygiene self monitoring of meds and / or other non-weight bearing assistance.

EXTENSIVE ASSISTANCE: While individual performs part of activity, substantial or consistent hands-on assistance with eating, toileting, bathing,

dressing, personal hygiene, self-monitoring of meds and / or weight bearing assistance is needed.

FULL DEPENDENCE: Full performance of activity by another.

B. ADL Support Provided Scores

0. No set-up or physical help needed 1.Set-up help only 2.One person physical assist 3.Two+ persons assist and/or one person assist w/assistive equipment

19.

Ambulation:

Note assistive equipment patient is to use while ambulating:

Cane

Quad cane

Walker

Bed/chair bound

other ______________________

20.

Non-

Moving to and between surfaces: bed, chair, wheelchair, standing position.

ambulatory/

Note assistive equipment patient is to use during transfer:

Manual wheelchair

Electric wheelchair

Hoyer lift

Transfer:

Transfer Board

Trapeze Bar

other ____________

Note self sufficiency once transferred __________________________________________________________

21.

Nutrition:

Check assistance needed with taking in food by any method.

Oral

Parenteral

Tube________

Feed patient

Set-up only

Dietary Restrictions_______________________________________

Supplements__________________________

Diet Ordered___________________________________ Meal Prep:

1 meal_________

2meals_________

Kitchen cleanup (cleaning table, stove, washing dishes, putting away items used, sweeping)__________________________

22.

Respiration:

Normal

Dyspneic with minimal exertion

Tracheostomy

Mechanical

Oxygen:

Continuous

Intermittent

Nebulizer Treatments _______________

A. Dust______________ B. Vacuum_______________ C. Mop________________ D. Sweep________________

23.

Endurance:

Pt. is never short of breath (SOB)

Pt. is SOB when walking more than 20 feet or climbing stairs

Patient is SOB when walking less than 20 feet and or dressing self or using commode

Pt is SOB w/minimal exertion (i.e. eating, talking, performing ADLs, agitation)

Pt is SOB at rest

Pt has generalized weakness

A. Change bed linens________ B. Make bed__________ C. Grocery shop________ D. Pick-up medicine________

E. Pay utility bills _______________ F. Take out garbage_____________

Check smoke alarm: _____

24.

Skin:

Normal

Dry, cracked or bleeding areas

Pressure areas

Decubiti

A. Diabetic foot care required?:

Yes

No Freq:__________

B. Nail Care?:

Yes

No Freq:___________

25.

Bathing:

A. Taking full body bath_______________ B. Shower_________________ C. Sponge bath__________________

D. Shampooing hair____________________ E. Clean bathroom after bathing____________________

Transferring in and out of tub and shower

Devices needed:

Shower bench

Bath Safety Bars

Detachable shower head

26.

Personal

Combing hair

Brushing teeth

Cleaning dentures

Washing/drying face and hands and perineum

hygiene:

A. Braiding or setting hair___________ B. Shaving_____________

27.

Dressing:

Laying out clothes

Retrieving clothes from closet

Putting clothes on and taking clothes off

Donning/removing TED Hose

Donning/removing prosthesis

A. ROM_____________

B. Launder pt’s clothes, bed linens, towels, and washcloths________________________

28.

Bladder :

Rate assistance needed & frequency of assistance needed for cleaning, changing or transferring self.

Normal

Ileostomy

Indwelling catheter

Condom Catheter

Occasional incontinence (less than daily)

Daily incontinence

Incontinence during the day and night

Devices/supplies needed:

Bed/chair bound

Bedside commode

Elevated Toilet Seat

Bedpan

Urinal

Pads

Diapers

Cath Care

29.

Bowel:

Rate assistance needed & frequency of assistance needed for cleaning, changing or transferring self.

Normal

Occasional Incontinence (less than daily)

Daily incontinence

Constipation

Ostomy

Devices/supplies needed:

Bedside Commode

Elevated Toilet Seat

Bedpan

Pads

Diapers

Enemas______________

Bowel Program____________________

30.

Self-

Self-monitoring of:

Pre-poured medications

Blood Sugars: Notify MD if BS is above_____ or below_____

monitoring:

BP: Notify MD if BP is > ______ or < ______

Weight: Notify MD if pt. loses or gains ____lbs. within ____days.

DMA-3000 Physician Authorization for Certification and Treatment (PACT) Form

Page 2 of 4

PATIENT FIRST & LAST NAME:	MEDICAID ID#:	ASSESSMENT DATE:

Other Client Information

Check the appropriate box if it applies to the patient.

31.

Pain:

Location of pain________________________ Severity of Pain: Rate 0 – 10: O=no pain and 10=worst pain ______

7-day look-back

Pain frequency:

No pain

Pain < daily

Pain > daily

Pain control:

No pain

Pain improved with medication

No pain relief or improvement w/medication

Cognitive Skills

Independent (decisions consistent/reasonable)

Modified independence (some difficulty in new situations only)

32.

for Daily

Moderately impaired (decisions poor, cues/supervision required)

Severely impaired (never/rarely makes decision)

Decision Mkg:

Patient requires step-by-step verbal prompting

MR/DD ___________________ (level)

33.

Behavior:

Cooperative

Passive

Physically abusive

Verbally abusive

Wanders

Injures self/others/property

Non-responsive

34.

Vision:

Adequate for daily activities

Limited (sees large objects)

Very limited (blind) Client uses:

Glasses

Contacts

35.

Hearing:

Adequate for daily activities

Hears loud sounds/voices

Very limited (deaf)

Client uses:

Hearing aids

36.

Speech:

Normal

Slurred

Weak

Other impediment: specify_____________

Primary Language(s)Spoken____________________________________________

37.

Communication

Speech

Gestures

Writing

Assistive Device: specify type ___________________________________________________

Method:

Client unable to write; have client make mark here: ______________________

Nurse’s initials: _________________

38.

Additional time needed. Document here information specific to client needs for other covered home management tasks AND exceptions requiring

additional time over identified time guidance:

39.

Patient’s perception of what he/she thinks their needs are:

40. Please check if any of the following apply to this patient:

Presence of continuous and/or substantial pain interfering with individual’s activity or movement

Dyspneic or noticeably short of breath with minimal exertion during ADL performance and requires continuous use of oxygen

Due to cognitive functioning, individual requires extensive assistance in routine situations. Individual is not alert and oriented or is unable to shift attention and

recall directions more than half the time.

Bowel incontinence more often than once daily

Urinary incontinence during the day and night

41.

Has the patient executed an advance directive (living will or durable power of attorney)?

Yes If yes, specify location of original doc.: ______________

42.

Is there a DNR order?

Yes

If yes, was DNR order discussed with pt.?

Yes

Has a copy of the DNR been obtained?

Yes

If no, has the MD been contacted to obtain copy?

Yes No

43.

SAFETY ASSESSMENT: Is the patient’s home adequate or suitable to carry out the Plan of Care according to your agency’s policies?

Yes

Water: ___________________________ Telephone: ____________________________ Heating: _________________________ Cooling: ___________________

Electric Capability Sufficient? Yes No	Is there a smoke alarm in the home?			Yes	No	Is there a fire extinguisher in the home?	Yes	No
If O2 is in use, have safety precautions been included on Plan of Care?		Yes	No	N/A	Are there safety devices located in the bathroom?		Yes	No
Are patient emergency numbers in clear view?	Yes No	Is the patient confined to bed or chair? Yes No
Has patient been instructed on the use of Durable Medical Equipment?		Yes	No	List the DME company used : _________________________________

Specify what DME is already available: _________________________________________________________________________________________________

Specify what DME has been ordered: __________________________________________________________________________________________________

44. Are there sources (family, friends, programs, or agencies) available to meet the above needs at the time that services have been requested?

Yes

NURSE ASSESSOR CERTIFICATION

I certify that I, and no one else, have completed the above in-home assessment of the patient’s condition. Falsification: an individual who certifies a material and false statement in this assessment will be subject to investigation for Medicaid fraud and will be referred to the NC Board of Nursing for investigation.

Based on the assessment, I have determined that the patient needs Personal Care Services due to the patient’s medical condition. I have developed the plan of care to meet those needs.

I have determined that the patient does not meet the criteria for personal care services.

_____________________________________________	__________________________________ ___________________________________
PRINT RN NAME	RN SIGNATURE	Date Signed: Time in /out of home
DMA-3000 Physician Authorization for Certification and Treatment (PACT) Form		Page 3 of 4

PATIENT FIRST & LAST NAME:

MEDICAID ID#:

ASSESSMENT DATE:

PLAN OF CARE

45.If the assessment indicates that the patient has medically-related personal care needs requiring Personal Care Services, show the plan for providing care beside the day(s) services are needed. Please write in the category # of the assigned task(s) that is designated on the assessment. The key below lists the category numbers. Be sure to write in the time (in 15 minute increments or in hours) required for each day.

Category #	Category Name	Category #	Category Name
19	Ambulation	27	Dressing
20	Non-ambulatory/Transfer	28	Bladder
21	Nutrition	29	Bowel
22, 23	Respiration	30	Self-monitoring
23	Endurance	30	Medication Assistance
24	Skin	31	Pain
25	Bathing	32	Cognitive Skills for Daily Decision-making
26	Personal hygiene	33	Behavior

Day of the	Task(s) To Be Accomplished	Total Time per Day
Day of the	Task(s) To Be Accomplished	(in 15 min increments
Week	Specify the category # and the amount of time required for each task (i.e. # 19: 15 minutes)	(in 15 min increments
Week		or in hours)
		or in hours)
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

46. Goals/Objectives: The need for PCS is expected to

change OR

end on _____/______/_____. If no change is expected, state why:

______________________________________________________________________________________________________________________

47. Has a verbal order been obtained to assess the patient and determine eligibility for PCS per DMA Guidelines?

Yes Date:_____________

48. Specify the date that a verbal order was obtained to start PCS:____________ Who conveyed/obtained this verbal order?_________________

PHYSICIAN CERTIFICATION

I certify that I am the patient’s primary physician and the patient is under my care and has a medical diagnosis with associated physical/mental limitations warranting the provision of the Personal Care Services in the above plan of care. Falsification: an individual who certifies a false statement in this plan may be subject to investigation for Medicaid fraud and will be referred to the North Carolina Board of Medicine.

ATTENDING PHYSICIAN’S SIGNATURE ____________________________________________	DATE________________________
DMA-3000 Physician Authorization for Certification and Treatment (PACT) Form	Page 4 of 4

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1. It's important to fill out the pcs physician authorization for certification and treatment accurately, therefore be careful when filling in the parts containing these specific blank fields:

dma 9052 form completion process shown (part 1)

2. The next stage is usually to fill out these blank fields: ADDRESS, DATE OF MOST RECENT EXAM mmddyy, REASON FOR REFERRAL, DIAGNOSIS Specify date of onset, Referral Source, CURRENT CARE Type and Source, ASSESSMENT, LIST ALL MEDICATIONS BELOW, SelfAdministered, Yes No If no who assists, Reminders needed, and Yes.

The right way to fill in dma 9052 form step 2

3. The next part is straightforward - fill in all the empty fields in No Known Allergies, Yes If yes LIST ALL KNOWN, Does the individual have any, DMA Physician Authorization for, and Page of to complete this process.

Learn how to fill out dma 9052 form part 3

4. This next section requires some additional information. Ensure you complete all the necessary fields - PATIENT FIRST LAST NAME, MEDICAID ID, ASSESSMENT DATE, Limitations in Activities of Daily, A ADL SelfPerformance Scores, INDEPENDENT No help needed or, B ADL Support Provided Scores No, Ambulation, Note assistive equipment patient, Quad cane Walker, Bedchair bound, other, Non ambulatory Transfer, Moving to and between surfaces bed, and Manual wheelchair - to proceed further in your process!

Part number 4 for submitting dma 9052 form

5. The last notch to submit this document is essential. Ensure you fill out the appropriate form fields, such as Respiration, Endurance, Dietary Restrictions Supplements, Normal Dyspneic with minimal, meal, Oxygen Continuous A Dust B Vacuum, Intermittent Nebulizer Treatments, Pt is never short of breath SOB, Pt is SOB when walking more than, Pt is SOB at rest, A Change bed linens B Make bed C, Skin, Normal Dry cracked or bleeding, Pressure areas Decubiti, and Bathing, before submitting. Neglecting to do it may lead to an unfinished and probably incorrect paper!

Be really mindful when filling out Oxygen Continuous A Dust B Vacuum and Endurance, because this is the part where many people make a few mistakes.

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