PCA - Forms - Minnesota Department of Human Services (DHS) 2026

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The document is a form for requesting technical changes to existing Personal Care Assistance (PCA) service authorizations in Minnesota. It outlines the process for submitting requests, including changes in provider, eligibility updates, and other modifications. The form requires specific member and provider information, as well as signatures when applicable.

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Click ‘Get Form’ to open the PCA Technical Change Request in the editor.
In the 'Request Type' section, select the type of change you are requesting. Fill in the 'Change Start Date' and 'End Date' as applicable.
Provide 'Member Information' by entering the member's complete legal name, 8-digit member ID number, date of birth, and selecting either PCA Traditional or PCA Choice.
Fill out the 'Provider Agency Information' by entering the agency name, NPI or UMPI, requestor's name and title, along with their phone and fax numbers.
If applicable, provide any additional information regarding your request in the 'Additional Information' section.
If you selected 'New Provider', ensure that the member or responsible party signs in the designated area.

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Versions	Form popularity	Fillable & printable
2020	4.5 Satisfied (47 Votes)
2017	4.4 Satisfied (33 Votes)
2012	4.5 Satisfied (40 Votes)

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