Personal Care Assistance

Forms

Lead agency forms

Communication to Physician of PCA Services (DHS-4690) (PDF)PCA Assessment and Service Plan (DHS-3244) (PDF)
PCA Assessment and Service Plan Instructions and Guidelines (DHS-3244A) (PDF)PCA Decision Tree (DHS-4201) (PDF)
PCA Request Fax Form (DHS-4292) (PDF)
Referral for PCA Services (DHS-3244P) (PDF)
State Agency Appeals Summary (DHS-0035) (PDF)
Supplemental Waiver PCA Assessment and Service Plan (DHS-3428D) (PDF)
Tribal Provider Statement of Assurance for PCA Assessment (DHS-5857) (PDF)

PCA provider forms

Direct Deposit Authorization for Electronic Funds Transfer Bank Change Request
Group, Facility or Billing Entity MHCP Provider Information Change (DHS-3535A) (PDF)
PCA Technical Change Request (DHS-4074A) (PDF)
Home Care Shared Services Agreement (DHS-5899) (PDF)
Individual PCA Information Change Form (DHS-5716) (PDF)
Individual PCA Relationship Acknowledgement (DHS-6426) (PDF)
PCA Time and Activity Documentation (DHS-4691) (PDF)
PCA Program Responsible Party Agreement and Plan (DHS-5856) (PDF)
Referral for PCA Services (DHS-3244P) (PDF)

PCA provider enrollment forms

Designation of PCA Billing Person (DHS-6000) (PDF)
Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF)
Individual PCA Enrollment Application (DHS-4469) (PDF)
Individual PCA Provider Agreement (DHS-4611) (PDF)
Individual PCA Provider Agreement Addendum (DHS-4468) (PDF)
MHCP Organization – Provider Enrollment Application (DHS-4016A)
MHCP PCPO/PCA Choice Agency Enrollment Application (DHS-4022) (PDF)
MHCP Provider Agreement (DHS-4138) (PDF)
PCA Agency Applicant Assurance Statement (DHS-6005) (PDF)
PCA Agency Personnel List and Affiliation (DHS-6041) (PDF)
PCA Agency Surety Bond (DHS-6033) (PDF)
Provider Agreement Addendum – PCPO (DHS-4022A) (PDF)
Provider Agreement Addendum – PCA Choice Provider (DHS-4022B) (PDF)
Qualified Professional (QP) Acknowledgement (DHS-4022C) (PDF)
Request for Resubmission - Individual PCA Enrollment Application/Agreement (DHS-5678) (PDF)

PCA consumer forms

Appeal to State Agency (DHS-0033) (PDF)
Civil Rights Complaint Form: Discrimination in Service Delivery (DHS-2807) (PDF)
Home Care Shared Services Agreement (DHS-5899) (PDF)
Individual PCA Relationship Acknowledgement (DHS-6426) (PDF)
MHCP Change Report Form (DHS-4976) (PDF)
PCA Time and Activity Documentation (DHS-4691) (PDF)
PCA Program Responsible Party Agreement and Plan DHS-5856 (PDF)