EPSDT PCS Plan of Care Form & Instructions

Issued 06/20/2008

EPSDT PCS Plan of Care Online Form
Click to view/print the EPSDT Plan of Care Form

Type of Plan of Care

Check the appropriate box to identify the Plan of Care:

New – Used for agency’s initial Plan of Care for recipient
Renewal – Used for Plan of Care completed for each new authorization period
Reconsideration – Used when the Plan of Care changes during the authorization period

Date Services Requested to Start

Complete with the date the provider agency is requesting to start providing services.

Identifying Information

· Name – Recipient’s name

ID# - Medicaid recipient number
DOB – Recipient’s date of birth
Address – Recipient’s address (street and city)
Home Phone# - Recipient’s home phone number
Cell Phone # - Recipient’s cell phone number

Provider Information

· Provider Agency Name – Name of the provider agency requesting authorization

Provider Number – Provider agency’s assigned Medicaid provider number
Provider Phone Number – Phone number of provider agency
Address – Provider agency’s mailing address (street, city and ZIP Code)
Contact person, e-mail and Phone # - Name of provider agency’s representative and e-mail address

Medical Reasons Supporting the Need for PCS

Summarize the recipient’s medical condition. If the recipient’s parent(s) or primary care giver(s) are disabled, summarize the parent(s) or primary care giver(s) medical condition and provide medical documentation from his/her physician that includes this individual’s functional limitations and how it affects the care of the recipient.

Other In-Home Services Requested or Currently Receiving

Identify all in-home services the recipient is currently receiving or has requested.

Personal Care Tasks

For the personal care tasks of “Bathing”, “Dressing”, “Grooming”, “Toileting”, “Eating”, “Meal Prep” and “Incidental Household Services” that the recipient requires assistance with because of his/her disability, complete the following:

· Goal – include the goal for the personal care task

# of Days Requested per Week - indicate the number of days during the week assistance is being requested with the personal care task
Time Requested to Complete Activity – indicate the time required in minutes to complete the activity, (i.e., 15 minutes, 30 minutes, etc.)
Total Time Requested for Week – indicate the total time requested for the week by multiplying the number of days the service is requested by the time requested to complete the activity to obtain the total time needed each week to complete the task, (i.e., 1 hour 15 minutes, 3 hours 30 minutes, etc.)
Total Weekly Hours Requested for Activities of Daily Living – add the Total Time Requested for Week for each PCS Activity to obtain the total time requested for the week to complete the covered personal care tasks

For the personal care task of “Accompanying to Medical Appointments”, complete the following when it is medically necessary that someone accompany the recipient and his/her caregiver to medical appointments:

· Goal – include the goal for the personal care task

· Frequency of Medical Appointments – indicate the frequency the recipient typically has medical appointments within the prior authorization period, (i.e., weekly appointment, monthly appointment, etc.)

· Time per Trip – indicate the time it typically takes the recipient to complete the medical appointment, (i.e., 1 hour, 2 hours, etc.)

Child Care Arrangements

Child care arrangements must be indicated for children 14 years of age or younger, or 15 years of age or older if they are unable to self direct their own care. If service is requested for a recipient meeting this criteria, and the parent(s) or primary care giver(s) are working or not in the home, indicate child care arrangements. Note: child care provider must be 18 years of age or older.

Signatures

A signature and date from the parent/guardian, the provider and the physician are required.