Get Individual Pca Enrollment Application - Trusted Home Care

Completing the Individual PCA Enrollment Application - Trusted Home Care is an essential step for individuals seeking to provide personal care services. This guide will walk you through each section of the application, ensuring you understand what information is required and how to provide it accurately.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the application form and open it for editing.
2. Begin by entering the legal name of the individual PCA in the designated fields, including first, middle, and last names. Ensure that the information matches legal documents.
3. Fill in the social security number of the individual PCA. This information is crucial for identification and eligibility verification.
4. Provide the residential address of the individual PCA. Do not use a P.O. Box; this must be the physical address.
5. Enter the date of birth and county of residence of the individual PCA, ensuring that the dates are formatted correctly.
6. Indicate whether the individual is 18 years or older by checking the appropriate box.
7. Complete the background study number and ensure all training information is correct, including the date DHS training was completed and the training certification number.
8. Read and certify the information provided is true and correct by signing the form and printing your name and date of the signature.
9. If applicable, provide information for group affiliation with other agencies owned, including organization/agency names and their respective NPI/UMPI numbers.
10. Finally, review the entire application for completeness, including all bolded fields. Once verified, fax both this application and the associated provider agreement to the specified number.

Complete your application online today for streamlined processing and support on your journey to providing care.