Follow the steps to successfully complete the Ucare PCA Authorization Transfer Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member information in the designated fields. Provide the first name, last name, address, city, zip code, gender, diagnosis, UCare ID, PMI number, phone number, date of birth, and ICD-10 code.
3. Proceed to fill out the primary care physician information, including the physician's name, primary clinic, phone number, and fax number.
4. Next, complete the previous health plan authorization information section. Enter the previous health plan name, previous authorization details, approved dates of service, the number of PCA hours authorized per day, and PCA units used.
5. Continuing, fill in the PCA provider information, which requires the PCA agency name, agency UCare provider ID, names of PCA caregivers, agency phone number, additional information, PCA units remaining, agency tax ID, agency contact person, and UMPI numbers for the caregivers.
6. Gather and attach the required documents: a copy of the current approved PCA service agreement from the previous health plan, the most recent PCA Assessment and Service Plan, and the completed PCA Assessment Request Form if due for annual reassessment.
7. Finally, read the declaration statement carefully. Print your name, sign, title, and the date to complete the form. Ensure all sections are filled accurately before finalizing.
8. After filling out the form completely, you can save your changes, download, print, or share the form as needed.

Complete your Ucare PCA Authorization Transfer Form online today to ensure a seamless transition!