Dma 3051 Form PDF Details

The Dma 3051 form, a crucial document within North Carolina's Department of Health and Human Services – Division of Medical Assistance, serves as an extensive request form for Personal Care Services (PCS). This form, which must be submitted to Liberty Healthcare Corporation-NC through fax or mail, stands as a prerequisite for individuals seeking PCS under Medicaid’s coverage. It meticulously collects information ranging from recipient demographics to medical history, emphasizing both the current medical conditions and their impacts on the individual's daily living activities. Moreover, it encompasses sections for new referrals, changes of status, and even a provision for physician attestation for cases necessitating over 80 hours of PCS, reflecting a comprehensive approach to evaluate and address the recipient's needs thoroughly. This form further navigates through the administrative procedures for changing providers, ensuring flexibility and adaptability to the recipient's evolving needs. The meticulous adherence to instructions for completing the form is underscored, indicating its significance in the timely and efficient processing of PCS requests, thereby illuminating its role as a linchpin in ensuring recipients receive the necessary care and services tailored to their conditions.

QuestionAnswer
Form NameDma 3051 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesPCS, dma 3051 pcs request for services form, NPI, dma 3051 form

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N.C. Department of Health and Human Services – Division of Medical Assistance

PERSONAL CARE SERVICES (PCS) REQUEST FOR SERVICES FORM

Completed form should be sent to Liberty Healthcare Corporation-NC via fax at 484-434-1571 or 855-740-1600 (toll free) or mail: ATTN: Liberty Healthcare Corporation, PCS Program 5540 Centerview Dr. Suite 114, Raleigh, NC 27606-3386. For questions, contact 855-740-1400 or 919-322-5944 or send an email to NC-IAsupport@libertyhealth.com. DISCLAIMER: Adherence to the INSTRUCTIONS for the Request for Services Form is

REQUIRED. If a request for services form is submitted incomplete, an unable to process notification will be issued and a new request for services form will be required. For the Expedited Assessment Process contact Liberty Healthcare Corporation at 1-855-740-1400

PROVIDER TYPE (select one)

 

 

DATE OF REQUEST:

(mm/dd/yyyy)

 

 

 

 

 

 

Home Care Agency

Family Care Home

Adult Care Home

Adult Care Bed in Nursing Facility

SLF-5600a

SLF-5600c

Special Care Unit (stand-alone Special Care Unit or SCU bed)

 

 

 

 

 

 

 

SECTION A. RECIPIENT DEMOGRAPHICS

Medicaid ID#:

Recipient’s Name (as shown on Medicaid Card) First:_______________________________ MI:____ Last:______________________________

Date of Birth:

(mm/dd/yyyy)

Gender:

Male

Female

Primary Language:

English

Spanish

Other

Address:

 

 

 

 

 

 

 

 

 

City: __________________________________________

County:

 

 

 

Zip:

 

 

 

(zip code + 4 digit extension) Phone: ________________________________

Alternate Contact/Parent/Guardian (required if patient under 18): First:______________________________ Last: _______________________

Relationship to Patient:

 

Phone: _____________________________________

Provider Name (if applicable)

 

Provider Phone:______________________________

SECTION B. RECIPIENT’S MEDICAL HISTORY – complete this section only if submitting a NEW REFERRAL or CHANGE OF STATUS request.

List BOTH the current medical diagnoses and ICD-9 codes that currently limit patient’s ability to independently perform Activities of Daily Living (bathing, dressing, mobility, toileting, and eating), prepare meals, and manage medications.

Medical Diagnosis

ICD-9 Code

Enter “O” for Onset or “E” for Exacerbation

Date (mm/yyyy)

SECTION C. NEW REFERRAL REQUEST complete this section if submitting a New Referral.

Check the box to the left and complete sections A, B, and C if submitting a New referral.

Referral Entity (select one):

Primary Care Physician

 

Attending MD

Physician Assistant (PA)

Nurse Practitioner (NP)

Is Recipient Medically Stable:

Yes

No

Is there an active Adult Protective Services (APS) case:

Yes

No

Date of last visit to Referring Entity: ___________________________(mm/dd/yyyy)

 

 

 

 

 

 

Other state/federal programs recipient is currently receiving (select all that apply):

 

Medicare Home Health

Private Duty Nurse

CAP

Hospice

Unknown

 

 

 

 

 

 

 

 

 

 

 

Is 24-hour caregiver availability required to ensure recipient’s safety?

Yes

No (e.g., Does patient have unscheduled ADL

needs or require safety supervision or structured living, or is patient unsafe if left alone for extended periods?)

 

 

 

Is recipient currently hospitalized or in a medical facility:

Yes

No

If yes, planned discharge date:

 

 

(mm/dd/yyyy)

Is recipient currently in a Skilled Nursing Facility (SNF):

Yes

No

if yes, planned discharge date: ____________(mm/dd/yyyy)

Referring Entity’s Name: ________________________________________________________________ NPI#:_________________________

Practice Name: ______________________________________________________________________________________________(if applicable)

Name of Practice Point of Contact:

 

 

 

 

 

 

 

Position: ______________________________

Phone (including area code): _____________________________________

Fax (including area code): ______________________________

Point of Contact’s Email Address:_______________________________________________________________________________________

Referring Entity/Practitioner Signature: ______________________________________________ Date: ___________ (mm/dd/yyyy)

NOTE: Dated signature is verification that the information in sections A, B, and C is accurate for this recipient and authorization to conduct a PCS

eligibility assessment. If requesting an assessment for greater than 80 hours of PCS completion of sections A, B, C, and E with a second signature

is REQUIRED on page 2. If not stop here and submit to Liberty.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMA 3051

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12/01/2013

 

 

 

 

 

Page 1 of 3

 

 

 

 

 

 

 

 

SECTION D. CHANGE OF STATUS REQUEST – complete this section if submitting a Change of Status (COS).

Check the box to the left and complete sections A, B, and D if submitting a Change of Status. If the Change of Status is requesting an assessment for greater than 80 hours of PCS completion of Sections A, B, D, and E are REQUIRED.

Requested By (select one): Primary Care Physician

Attending MD

PA

NP

PCS Provider

Recipient

Responsible Party

Other (Relationship to Recipient): _______________________________

Is Recipient Medically Stable:

Yes

No

Is there an active Adult Protective Services (APS) case:

Yes

No

Reason for Change in Condition Requiring Reassessment:

Change in medical condition

Change in recipient’s location affecting ability to perform ADLs

Change in caregiver status

Hospitalization Discharge Date:

 

(mm/dd/yyyy)

Other: ___________________________________________________________________________________________

Describe the specific change in condition and its impact on the recipient’s need for hands on assistance (required for all reasons):

Provider 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: ____________________________

Practice Phone_______________________________________ Practice Fax: ___________________________________

Email: ______________________________________________________________________________________

Referring Entity/Practitioner Information (Complete if change of status is submitted by the recipient’s PCP, Attending MD, PA, or NP). Practitioner First Name: ___________________________ Last Name:________________________ NPI#:__________________

Practice Name: ___________________________________________________________________________________(if applicable)

Practice Contact’s Name: ___________________________________ Contact’s Position: ________________________________

Practice Phone_______________________________________ Practice Fax: _____________________________________

Email: ______________________________________________________________________________________

SECTION E. PHYSICIAN ATTESTATION: Session Law 2013-306 requires that a physician attest that the recipient meets each of the criteria below to be eligible for up to 50 additional hours of PCS as determined through the independent assessment.

The recipient requires an increased level of supervision.

The recipient 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.

Regardless of setting, the recipient requires a physical environment that includes modifications and safety measures to safeguard the recipient because of the recipient's gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning, and the loss of language skills.

The recipient has a history of safety concerns related to inappropriate wandering, ingestion, aggressive behavior, and an increased incidence of falls.

Referring Entity/Practitioner Signature: ____________________________________________ Date: ______________(mm/dd/yyyy)

NOTE: If submitting a New Referral or Change of Status (COS) is requesting an assessment for greater than 80 hours the dated signature is verification that information in sections A, B, C, D (if COS) & E are accurate for this recipient and authorization to conduct the PCS eligibility assessment. If submitting a Physician Attestation only the dated signature is verification that information in

DMA 3051

 

12/01/2013

Page 2 of 3

sections A, B and E are accurate for this recipient and authorization to conduct the PCS eligibility assessment.

SECTION F. CHANGE OF PROVIDER REQUEST – complete this section if submitting a Change of Provider (COP).

Check the box to the left and complete sections A and F only.

Requested By (select one):

Primary Care Physician

Attending MD

Physician Assistant

Nurse Practitioner

 

Recipient

Responsible Party

 

 

NOTE: Home Care Agencies and Licensed Residential Facilities should have beneficiaries or the recipient’s legal representatives to call the Liberty Healthcare Corporation-NC Call Center for Change of Provider (COP) requests at 855-740-1400 or 919-322-5944. Home Care Agencies and Licensed Residential Facilities may assist the recipient or legal representative in placing the call.

Reason for Provider Change (select one):

Recipient 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 recipient is established with a new provider agency; no discharge/transfer is planned

Recipient’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 (stand-alone Special Care Unit or SCU bed)

 

 

Agency Name:_____________________________________________________

Phone: ________________________________

 

Provider NPI#: ___________________________________

PCS Provider Locator Code#: _________________(three digit code)

 

Facility License # (if applicable): ________________________

License Date (if applicable): _____________________(mm/dd/yyyy)

 

Physical Address:

 

 

 

 

 

 

_____________________________________________________________________________________________

 

 

 

 

 

 

 

 

Recipient’s Alternate 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 (stand-alone Special Care Unit or SCU bed)

 

 

Agency Name:_____________________________________________________

Phone: ________________________________

 

Provider NPI#: ___________________________________

PCS Provider Locator Code#: _________________(three digit code)

 

Facility License # (if applicable): ________________________

License Date (if applicable): _____________________(mm/dd/yyyy)

 

Physical Address:

 

 

 

 

 

 

_____________________________________________________________________________________________

 

 

 

 

Contact Information for Questions about Change of Provider Request (if not recipient or alternate contact listed in section A).

 

Contact’s Name: _________________________________________

Relationship to Recipient: _________________________

Phone: ______________________ Fax: ______________________

Email: ___________________________________________

DMA 3051

 

12/01/2013

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1. The dma3051 usually requires particular details to be typed in. Ensure the next blanks are filled out:

Step number 1 of submitting SLF5600a

2. The subsequent part is to fill in all of the following blank fields: Medical Diagnosis, ICD Code, Date mmyyyy, Enter O for Onset or E for, SECTION C NEW REFERRAL REQUEST, Check the box to the left and, Referral Entity select one cid, Date of last visit to Referring, cid CAP cid Hospice cid Unknown, Is hour caregiver availability, Referring Entitys Name NPI, Practice Name if applicable, Name of Practice Point of Contact, Position, and Phone including area code Fax.

Filling out segment 2 of SLF5600a

3. Completing Point of Contacts Email Address, DMA, and Page of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

How you can complete SLF5600a stage 3

4. Your next part will require your attention in the subsequent areas: SECTION D CHANGE OF STATUS REQUEST, Check the box to the left and, Requested By select one cid, cid Change in medical condition, mmddyyyy, Provider Name, and PCS Provider NPI PCS Provider. Make certain you fill in all required details to go further.

Stage # 4 of filling in SLF5600a

It is easy to make errors when filling out the mmddyyyy, consequently make sure to look again before you decide to finalize the form.

5. Because you approach the conclusion of this form, you'll notice several more things to undertake. Mainly, Facility License if applicable, Provider Contact Name Contacts, Practice Phone Practice Fax, Email, Referring EntityPractitioner, Practitioner First Name Last Name, Practice Name if applicable, Practice Contacts Name Contacts, Practice Phone Practice Fax, Email, SECTION E PHYSICIAN ATTESTATION, The recipient requires an, The recipient requires caregivers, characterized by irreversible, and Regardless of setting the must all be filled out.

Step no. 5 for completing SLF5600a

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