Dma 3051 Form – Fill Out and Use This PDF

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

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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: ___________________________________________

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