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Click ‘Get Form’ to open the PCA form in the editor.
Begin by filling out the 'Individual PCA Information' section. Enter the legal name, social security number, residential address (no P.O. boxes), phone number, date of birth, and county of residence. Ensure all bolded fields are completed.
Indicate whether the individual is a new hire or rehire and confirm if they are 18 years or older by selecting 'YES' or 'NO'. If applicable, provide the employment end date.
In the 'Individual PCA Provider Statement', review and certify that all information is accurate. Sign and print your name along with the date signed.
If you wish to affiliate this PCA with other agencies you own, complete the 'Group Affiliation Information' section by entering the agency names and NPI/UMPI numbers.
Fill out your agency information including agency name, fax number, and personnel completing the form. Ensure to sign where indicated.
Finally, read and sign the Minnesota Health Care Programs Provider Agreement Individual Personal Care Assistant form (DHS-4611) and prepare both documents for faxing.
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Medical Eligibility for Home Care To qualify for a PCA, youll need to have either a chronic illness or injury or a physical, emotional, or mental disability.
How much does MassHealth pay PCA?
How To Become A PCA: Skill Education Requirements Obtain Necessary High School Diploma or Equivalent Education Level. Complete State-Approved Training Programs for Personal Care Aides. Acquire First Aid and CPR Certifications to Enhance Safety Skills. Develop Interpersonal Skills to Connect with Clients Effectively.
pca form pdf
Pca form pdfDHS PCA formsPca form onlineMN DHS PCA Technical Change FormMassHealth PCA application form PDFDHS-4469 FormIndividual PCA Enrollment ApplicationPCA Enrollment form
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