Get Pca Prior Authorization Adjustment Form (pdf) - Mass

Filling out the PCA Prior Authorization Adjustment Form is essential for individuals seeking adjustments to their PCA services. This guide will provide clear, step-by-step instructions on how to accurately complete the form online, ensuring that your request is properly submitted.

Follow the steps to fill out the PCA Prior Authorization Adjustment Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the PCA consumer's MassHealth ID Number and current authorization details in the designated fields.
3. Specify the activities of daily living (ADL) or instrumental activities of daily living (IADL) for which adjustments are requested.
4. Indicate the desired decrease or increase in PCA service frequency. Fill in the times per day and days per week for the requested PCA time in minutes.
5. Fill in the total minutes per week that are currently authorized and detail the total adjustment request, including the requested authorization.
6. In the section for the authorized PCM agency, fill in the total minutes requested per week and subtract the currently authorized minutes to show the adjustment.
7. Provide any comments that may clarify the adjustment request.
8. Complete the section regarding night-time PCA services by indicating the frequency and total billable hours, and include comments as necessary.
9. Indicate whether the consumer is receiving or about to receive any other home-based services.
10. In the remaining sections, the PCM agency must add additional comments and the necessary physician or nurse practitioner signature, followed by the review date and any other required details.
11. Once all sections are filled out, save your changes. You may also choose to download, print, or share the completed form.

Begin filling out the PCA Prior Authorization Adjustment Form online today to ensure your PCA service needs are met.