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REQUEST FOR MEDICAID EPSDT - PERSONAL CARE SERVICES

(Personal Care Services are to be provided in the home and not in an institution)

I. IDENTIFYING INFORMATION

1. Applicant Name:	MID#

Address:	Ph#
	(	)

	D Male	D Female		DOB:
	D Male	D Female

2. Responsible Party/Curator:	Relationship:

Address:	Home Phone #
		(	)

	Work or Cell Phone #
		(	)

By signing this form I give my consent for my medical information to be released to the Department of Health and Hospitals to be used in determining eligibility for Personal Care Services.

Signature:Date:

II. MEDICAL INFORMATION

NOTE: The following information is to be completed by the applicant’s attending practitioner.

1. Patient Name:

2. Primary Diagnosis:

Diagnosis

Code:

Secondary Diagnosis:

Diagnosis

Code:

3. Physical Examination:

4. Special Care/Procedures: check appropriate box and

General

Head and CNS

Mouth

give type, frequency, size, stage and site when appropriate

and EENT

Chest

Heart

D Trach Care: D Daily

D PRN

D Respiratory: D Ventilator D Daily D Other

and Circulation

Abdomen

Genitalia

Extremities

Skin

Height

D Suctioning/Oral Care: D Daily D PRN

D Glucose Monitoring:

D Insulin Injections

D Daily D Other

Wt.

Pulse

Resp

D Restraints (positioning)

Temp

B/P

Bowel/Bladder

D Dialysis

Control

D Urinary Catheter

Impaired Vision

Impaired Hearing

D Seizure Precautions

D Ostomy

DGlasses

DHearing Aid

D IV

Lab Results:

D Decubitus/Stage

HCT

HCB

U/A

D Diet/Tube Feeding

Radiology

D Rehab (OT,PT,ST)

Assistive Device:

Medications

Dosage

Frequency

Route

EPSDT-PCS Form 90

Revised May 2019

II. MEDICAL INFORMATION (Continued)

6.Recent Hospitalizations: (include psychiatric):

7.Mental Status/Behavior: Check Yes or No. If Yes, indicate frequency: 1 = seldom; 2 = frequent; 3 = always

Oriented	D Yes ( 1	2	3 )	D No	Depressed	D Yes ( 1		2	3	)	D No	Cooperative	D Yes ( 1	2	3	)	D No
					Physically	D Yes ( 1		2	3 )		D No	Verbally	D Yes ( 1	2	3	)	D No
Passive	D Yes ( 1	2	3 )	D No	Abusive	D Yes ( 1		2	3 )		D No	Abusive	D Yes ( 1	2	3	)	D No
Passive	D Yes ( 1	2	3 )	D No	Abusive							Abusive
Verbal	D Yes ( 1	2	3 )	D No	Comatose	D Yes	( 1	2	3	)	D No	Hostile	D Yes ( 1	2	3	)	D No
Forgetful	D Yes ( 1	2	3 )	D No	Confused	D Yes	( 1	2	3	)	D No	Combative	D Yes ( 1	2	3	)	D No
Non-	D Yes ( 1	2	3 )	D No	Injures	D Yes ( 1		2	3 )		D No
responsive	D Yes ( 1	2	3 )	D No	Self/Others	D Yes ( 1		2	3 )		D No
responsive					Self/Others

8.Impairments: Please rate the following. 1- Mild , 2-Moderate, 3-Severe

Walking	( 1	2	3 )	Chronic	( 1	2	3	)	Vision	( 1	2	3	)
				heart failure					impairment

Spasticity	( 1	2	3 )	Speech	( 1	2	3	)	Oral feeding	( 1	2	3	)
				impairment

Limb				Seizure					Bladder and
	( 1	2	3 )		( 1	2	3	)	bowel	( 1	2	3	)
weakness				Disorder
									incontinence

Hypotonia	( 1	2	3 )	Developmental	( 1	2	3	)	Intellectual	( 1	2	3	)
				delay					impairment

Chronic				Hearing
Resp	( 1	2	3 )		(1	2	3 )
				impairment
distress

				III. LEVEL OF CARE DETERMINATION
Activities of Daily Living:
Based on	the beneficiary’s impairment, the attending					practitioner should			check the	appropriate			box as it applies to

the beneficiary’s ability to perform this age appropriate tasks using the following definitions and PCS Level of Assistance Guide:

Not Independent at this Age – not age appropriate to perform this task independently Independent – beneficiary able to perform task without assistance

Limited Assistance – beneficiary aids in task, but receives help from other persons some of the time

Extensive Assistance – beneficiary aids in task, but receives help from other persons all of the time Maximal Assistance – beneficiary is entirely dependent on other persons

Note: An additional 15 minutes can be added to bathing, dressing and toileting if mobility/transfer assistance is required

(EPSDT – PCS Level of Assistance Guide)

This is a general guide to assist practitioners with determining the level of assistance beneficiaries require to complete their activities of daily living (ADL). Additional time to complete the tasks will be considered if there is sufficient medical documentation provided. Please use the comments section below and attach documentation to support the need for additional time to complete the ADL’s. In addition to the PCS tasks listed, assistance with incidental household chores may be approved. This does not include routine household chores such as regular laundry, ironing, mopping, dusting, etc., but instead arises as the result of providing assistance with personal care to the beneficiary.

		Levels of Assistance
PCS Task					Mobility/Transfer Requirement
	Independent	Limited	Extensive	Maximal
	Independent	Assistance	Assistance	Assistance
		Assistance	Assistance	Assistance
Bathing	0	15 min	30 min	45 min	Additional 15 min

Dressing	0	15 min	30 min	45 min	Additional 15 min

Grooming	0	15 min	15 min	15 min

Toileting	0	15 min	30 min	45 min	Additional 15 min

Eating	0	15 min	30 min	45 min
Meal Prep	0	30 min	30 min	30 min

EPSDT-PCS Form 90

Revised May 2019

III. LEVEL OF CARE DETERMINATION (Continued)

NOTE: The following information is to be completed by the applicant’s attending practitioner. Check the appropriate box using the definitions and EPSDT PCS Level of Assistance Guide to assist with determining the level of care.

Not

Limited

Extensive

Maximal

Activity

Independent

Comments

Assistance

at this Age

Bathing

Dressing

Grooming

Toileting

Eating

Level of care is provided under classifications dependent upon the type and/or complexity of care and services rendered, as well as, the

amount of time required to render the necessary care and services. Please select one of the following:

This individual’s condition includes a need for nursing care to manage a plan of care and/or more assistance with extensive personal care,

ambulation, and mobilization. May include professional nursing care and assessment on a daily basis due to a serious condition which is

unstable or a rehabilitative therapeutic regime requiring professional staff.

D Yes, this individual requires this level of care.

D No, this individual does not require this level of care.

Mobility/Transfer Requirements: Please indicate below the activities of daily living for which the beneficiary will require assistance with

mobility/transfer.

Bathing

D Yes D No

Dressing D Yes D No

Toileting

D Yes D No

Medical Appointments:

Will the beneficiary need the PCS worker to accompany him/her to medical appointments? D Yes D No

How often will the beneficiary have scheduled medical appointments?

D weekly D monthly D quarterly D other

Reason for PCS worker to accompany child to medical appointments:

IV. PRACTITIONER’S ORDER

The above named patient is in need of EPSDT PCS due to his/her current medical condition. I am prescribing

Personal Care Services for

hours,

days a week as determined by the level of care determination.

Practitioner’s Name (type or print):

Address:

Phone:

()

I certify/recertify that I am the attending practitioner for this patient and that the information provided is accurate and correct to the best of my knowledge. I authorize these EPSDT personal care services and will periodically review the plan. In my professional opinion, the services listed on this form are medically necessary and appropriate due to the child’s medical condition. I understand that if I knowingly authorize services that are not medically necessary, I may be in violation of Medicaid rules and subject to sanctions described therein. I understand a face to face evaluation must be held between beneficiary and practitioner.

Practitioner’s Signature

Date

EPSDT-PCS Form 90

Revised May 2019

EPSDT-PCS Form 90

Revised May 2019

Question	Answer
Form Name	Epsdt Pcs 90 Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	epsdt pcs, epsdt forms pdf, epsdt forms for mt, louisiana epsdt form 90

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