Get Pca Form 2020-2025

Filling out the PCA Form is a crucial step in enrolling an individual personal care assistant. This guide provides clear and detailed instructions to help users successfully complete the form online in a straightforward manner.

Follow the steps to complete the PCA Form online.

1. Press the ‘Get Form’ button to acquire the PCA Form and open it in your preferred editor.
2. Begin by filling in the legal name of the individual PCA in the designated fields for 'FIRST,' 'MIDDLE,' and 'LAST' names.
3. Enter the individual PCA's Social Security number in the corresponding field.
4. Provide the residential address, ensuring that a P.O. Box is not entered.
5. Fill in the city, state, and ZIP code information accurately.
6. Include the individual's date of birth, formatted as month/day/year.
7. Indicate the county of residence for the individual PCA.
8. If applicable, enter the NPI/UMPI number if reinstatement is being requested.
9. Record the date on which the DHS training was completed.
10. Enter the training certification number as required.
11. Select 'YES' or 'NO' depending on whether the individual is 18 years or older.
12. Indicate whether the individual has maintained continuous employment with the agency, selecting 'YES' or 'NO' appropriately.
13. If applicable, provide the employment end date.
14. Fill in the BGS number/request ID as prompted.
15. Review the 'Individual PCA Provider Statement' and ensure all information is accurate before signing.
16. Print or type the name of the PCA in the designated area and sign the form with the current date.
17. If the individual PCA is to be affiliated with other agencies, provide the necessary details, including organization/agency name and NPI/UMPI.
18. Complete the agency information, including agency name, fax number, NPI/UMPI, and the personnel completing the form.
19. Ensure all signature requirements are fulfilled.
20. Once completed, fax the PCA Form along with the Minnesota Health Care Programs Provider Agreement form (DHS-4611) to the designated number, ensuring that only faxed requests will be processed.

Submit your PCA Form online today to ensure a smooth enrollment process.