Personal Care Assistance (PCA) Program Responsible Party Agreement and Plan 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Responsible Party's name in the designated field, ensuring you include the last name, first name, and middle initial.
3. Next, specify your relationship to the recipient in the provided section.
4. Fill in the recipient's name and their MHCP ID number accurately.
5. Indicate the time period for which you agree to be responsible for the recipient by filling in both start and end dates.
6. Carefully review each responsibility listed and initial next to each item to confirm your agreement.
7. In the 'Responsible Party Plan' section, detail how you will meet these responsibilities. If necessary, attach an additional page.
8. Check the acknowledgment boxes confirming your age and that you are not affiliated with the PCA provider agency.
9. Sign and date the form at the bottom, then provide your address and phone number for contact purposes.

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