EPSDT Personal Care Services Plan of Care - Louisiana Medicaid 2025

1. Click ‘Get Form’ to open the EPSDT Personal Care Services Plan of Care in the editor.
2. Begin by filling out the Identifying Information section. Enter the recipient's name, date of birth, and address accurately.
3. In the Provider Information section, input the provider agency name, ID number, and contact details including phone number and email.
4. Detail the Medical Reasons Supporting the Need for PCS. Ensure you attach appropriate medical documentation as required.
5. Specify any Other In-Home Services currently received by checking relevant boxes such as Home Health Nursing Services or Mental Health Rehab.
6. In the Personal Care Tasks section, list each task requiring assistance. Fill in time requested and total time for each activity across the week.
7. Complete Child Care Arrangements if applicable, ensuring compliance with age requirements for supervision.
8. Finally, gather signatures from all necessary parties including parent/guardian and provider representative before submitting.

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