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PCA - Forms - Minnesota Department of Human Services (DHS) 2026
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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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technical change request form
Jun 30, 2018 DHS strives to achieve results in seven essential outcomes through its Minnesota Medicaid Managed Care Comprehensive Quality. Strategy: Read more
Please call 608-267-3543 for more information. Department of Health and Family Services guidance. Calling the publication request line at (608)-264-6009.
Personal care assistance (PCA) is a Minnesota health care program that provides services to seniors and people with disabilities to help them remain independentRead more