Individual Pca Form PDF Details

When it comes to adding or terminating individual Personal Care Assistant (PCA) service providers at Blue Cross and Blue Shield of Minnesota, the Individual PCA Data Sheet is an essential document for agencies to manage their personnel effectively. Whether for a supervisory or non-supervisory role, this form facilitates the smooth transition of staff changes, ensuring the accuracy of provider information within the organization's system. It requires detailed information about the PCA, including names, social security numbers, professional titles, and specific roles. Furthermore, agencies must provide their own details, such as agency name, ID, and contact information. The process is made clear with options to fax or mail the completed form, and there are dedicated phone numbers for any required support. The form also emphasizes the importance of compliance with state regulations, outlining the necessity for the sender to verify the qualifications of any Qualified Developmental Disabilities Specialist listed, as mandated. This ensures that only qualified professionals are added to the Blue Cross and Blue Shield of Minnesota network, adhering to high standards of care and legal requirements. Completing and submitting this form marks a significant step in maintaining up-to-date records and delivering quality care services.

QuestionAnswer
Form NameIndividual Pca Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesblue cross blue shield pca data sheet, individual pca form, individual pca, pca data sheet

Form Preview Example

Blue Cross and Blue Shield of Minnesota

Individual PCA Data Sheet

Fax to: (651) 662-6684 or

Mail to: BCBSMN PDO, R316 P.O. Box 64560

St. Paul, MN 55164-0560

Please complete this form when adding or terminating an invididual PCA service provider in a supervisory or non-

supervisory role.

If you have any questions, contact Provider Service at (651) 662-5200 or 1-800-262-0820.

Agency Information

 

 

 

 

Date of Request:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCA Agency Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BCBSMN ID #:

 

 

 

 

 

 

Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCA Agency NPI/UMPI #:

 

 

 

 

 

 

 

 

 

 

 

 

PCA Agency Tax ID #:

 

 

 

 

 

City:

 

 

St:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCA Information

Effective Date:

Add to this location

Term from this location

Last Name:

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

 

 

Mid Init:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI/UMPI #:

 

 

 

 

 

Gender:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisory position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date:

 

 

Add to this location

 

 

Term from this location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

 

Mid Init:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security #:

 

 

 

NPI/UMPI #:

 

 

 

 

 

Gender:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisory position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date:

 

 

Add to this location

 

 

Term from this location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

 

Mid Init:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security #:

 

 

NPI/UMPI #:

 

 

 

 

 

Gender:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisory position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date:

 

 

Add to this location

 

 

Term from this location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

Social Security #:

 

NPI/UMPI #:

 

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

First Name:

 

 

 

 

Mid Init:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervisory position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person Completing Form:

Signature:

E-Mail Address:

Phone #:

Fax #:

Submit by Email

Print

The Sender of this Form represents and warrants that he/she is authorized to submit these changes on behalf of the Provider.

**By submitting this Form, the Sender attests that he/she has verified the qualifications of any

Qualified Developmental Disabilities Specialists noted on this form, per MN State Statute 245B.07 Subdivision 4.**

To add more individual PCA service providers, please complete and submit a new Individual Data sheet

How to Edit Individual Pca Form Online for Free

Our PDF editor makes it simple to manage the individual pca form form. It will be easy to get the document in short order by following these simple actions.

Step 1: Hit the orange "Get Form Now" button on this web page.

Step 2: Once you have accessed the individual pca form edit page, you'll see all actions you may use concerning your file within the upper menu.

The following areas are what you are going to complete to obtain the ready PDF document.

blue cross blue shield of minnesota individual pca data sheet spaces to fill in

In the Last Name, Social Security, Title, Last Name, Social Security, Title, Effective Date, Add to this location, Term from this location, First Name, Mid Init, NPIUMPI, Gender, Date of Birth, and Effective Date field, write down your details.

Filling in blue cross blue shield of minnesota individual pca data sheet part 2

Step 3: Click the Done button to make sure that your finished file can be exported to each device you select or forwarded to an email you specify.

Step 4: To protect yourself from potential forthcoming issues, it's recommended to obtain minimally several duplicates of each separate file.

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