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Click ‘Get Form’ to open the DHS-4469-ENG in the editor.
Begin by filling out the 'Individual PCA Information' section. Enter the legal name, social security number, phone number, and residential address. Ensure you do not use a P.O. Box.
Complete the date of birth and training certification number fields. Confirm if the individual is 18 years or older by selecting 'YES' or 'NO'.
Indicate whether the individual has maintained continuous employment since their last Background Study (BGS) was completed 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 date this section.
If you wish to affiliate this PCA with other agencies, complete that section as well.
Finally, read and sign the Minnesota Health Care Programs Provider Agreement form (DHS-4611) before faxing both documents to (651) 431-7462.

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