Pca form 2026

1. Click ‘Get Form’ to open the PCA form in the editor.
2. 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.
3. 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.
4. In the 'Individual PCA Provider Statement', review and certify that all information is accurate. Sign and print your name along with the date signed.
5. 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.
6. Fill out your agency information including agency name, fax number, and personnel completing the form. Ensure to sign where indicated.
7. 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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