Personal Care Assistance Services Encounter Data and 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the PCA Agency name, ensuring it is printed or typed clearly. This identifies your organization.
3. Fill in the PCA Agency NPI or UMPI, followed by the street address, city, state, and ZIP code. Accurate agency information is crucial for compliance.
4. In the Agency Representative section, provide the representative's name and signature. Ensure you check the box if signing electronically.
5. Complete the Qualified Professional (QP) information by entering their last name, first name, middle name, and residential address. Include their license number and background study details.
6. Finally, review all entries for accuracy before submitting via the Minnesota Provider Screening and Enrollment portal or faxing to MHCP Provider Eligibility.

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