Individual pca 2026

1. Click ‘Get Form’ to open the Individual PCA Data Sheet in the editor.
2. Begin by filling out the Agency Information section. Enter the Date of Request, PCA Agency Name, BCBSMN ID #, Street, City, and Zip code. Ensure all details are accurate for smooth processing.
3. In the PCA Information section, specify whether you are adding or terminating a PCA service provider. Fill in the Effective Date and provide the Last Name, First Name, Mid Initial, Gender, Date of Birth, Title, and NPI/UMPI # for each PCA.
4. If applicable, indicate if the PCA holds a Supervisory position. Repeat this process for additional PCA providers as needed.
5. Complete the Person Completing Form section with your name, E-Mail Address, Signature, and Phone #. Review all entries for accuracy before submission.
6. Once completed, submit by Email or Fax using the provided contact information.

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