DHB-3051 - REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES (PCS) - ATTESTATION OF MEDICAL NEED

Q: What is the purpose of the DHB-3051 form?

The form is used to request a PCS Independent Assessment and Attestation of Medical Need based on ADL assistance needs.

Q: Which ADLs are referenced for PCS eligibility?

The ADLs listed are bathing, dressing, toileting, eating, and transferring/functional mobility in the home.

Q: What information is required in Section B about medical conditions?

Section B requires the medical diagnosis and the ICD-10 code, and the entered diagnosis/ICD-10 must relate to the ADL deficit for the request to be processed.

Q: Who completes Sections F–G and where are those sections located?

Sections F–G are for non-medical change of status and change of PCS provider requests, completed by the beneficiary, family member, legal guardian, home care provider, or residential provider on page 3 of the form.

Sep 19, 2026

Upload by Felix Montgomery

DHB-3051 is an instructions package for completing the Request for Independent Assessment and Attestation of Medical Need for Personal Care Services (PCS). It explains PCS as a Medicaid benefit tied to assistance needs for Activities of Daily Living (ADLs), defines required ADL-related diagnoses and ICD-10 codes, and outlines which parties complete Sections A–E (practitioner) versus Sections F–G (beneficiary or providers). It also covers request types, required dates, managed care disenrollment details, submission and contact information, and RSVP/RSID requirements for Adult Care Home referrals.

LanguageEnglish

CategoryForms

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

Instructions

Expedited assessment and contact information

Purpose and types of independent assessments

Sections A–E (practitioner completion)

Sections F–G (non-medical and provider changes)

Submission/fax contacts and RSVP/RSID note

DHB-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES ATTESTATION OF MEDICAL NEED INSTRUCTIONS These instructions offer guidance for completing the Request for Independent Assessment and Attestation of Medical Need Form for Personal Care Services (PCS) and should be read in its entirety before completing. Expedited Assessment Process Info: Contact NC LIFTSS 1-833-522-5429. Questions: Call or Email NC LIFTSS at 1-833-522-5429 or, [NCLIFTSS@Acentra.com](NCLIFTSS@Acentra.com) Personal Care Services (PCS) is a Medicaid benefit based on the need for assistance with Activities of Daily Living (ADLs) . The ADLs are bathing, dressing, toileting, eating, and transferring/functional mobility in the home. The purpose of the Request for Independent Assessment / Attestation of Medical Need Form (DHB-3051) is to request a PCS Independent Assessment. Requested assessments will be one of the following: Disenrollment, New Request, Change of Status (Medical or Non-Medical), or Change of Provider. Sections A – E: Change of Status: Medical, New Request, and Managed Care Disenrollment (located on pg. 1-2 of the form) shall be completed by a practitioner with section E completed by the PCS Provider if for Managed Care Disenrollment. Request Type: Select the type that indicates the reason for the request. Enter the Date of Request in the appropriate field. Section A: Beneficiary’s Demographics. The beneficiary’s name should be the same as it appears on their Medicaid card. Beneficiaries living in, and those seeking admission to, an Adult Care Home (ACH) will have the facility’s address and phone number. If identified as legal guardian or Power of Attorney (POA), submit guardianship/POA documents to NC LIFTSS. *The RSID \# and RSID Date is generated when a beneficiary, being referred or seeking admission to an ACH, is referred to a LME-MCO for the RSVP. Further information can be found below, pg 2. The Alternate Contact should not be a PCS Provider. Section B: Beneficiary’s Conditions. Enter information regarding current medical conditions that limit the beneficiary’s ability to perform, and resulted in a need for assistance with, ADLs. Medical Diagnosis and ICD-10 Code are both required fields. The Diagnosis and ICD-10 entered must relate to the ADL deficit for this request to be processed. Optional Attestation: This step is optional. Review each statement and initial, only if applicable. Section C: Practitioner Information. Enter Practitioner and Practice information in the appropriate field. You may use the practice stamp if applicable. Sign and date once completed. Signature stamps are not allowed. Section D: Change of Status: Medical. Complete if requesting a Medical Change of Status. Describe the medical change and its impact on the beneficiary’s need for hands on assistance. Section D, located on page 2, is a required field for all Medical Change of Status Requests. The date of the beneficiary’s last PCP visit must be < 90 days from Received Date by the IAE. It is required that the beneficiary’s PCP or inpatient practitioner complete this form. If beneficiary does not have a PCP, the practitioner, currently providing care and treatment for the medical, physical or cognitive condition causing the functional limitation, may complete the form. Section E: Managed Care Disenrollment: Medical. Complete if requesting disenrollment from Managed Care. Enter the information regarding the beneficiary’s current plan, date of enrollment, effective date of disenrollment, current approved PCS hours, and current PCS provider. Completed form should be faxed to NC LIFTSS prior to disenrollment date. ---PRACTITIONER FORM ENDS HERE--- Sections F – G: Non-Medical Change of Status and Change of Provider Requests, located on pg. 3 of the form, shall be completed by the beneficiary, family member, legal guardian, home care provider, or residential provider. Request Type. Select the Request Type that indicat

FAQs

What is the purpose of the DHB-3051 form?

The form is used to request a PCS Independent Assessment and Attestation of Medical Need based on ADL assistance needs.

Which ADLs are referenced for PCS eligibility?

The ADLs listed are bathing, dressing, toileting, eating, and transferring/functional mobility in the home.

What information is required in Section B about medical conditions?

Section B requires the medical diagnosis and the ICD-10 code, and the entered diagnosis/ICD-10 must relate to the ADL deficit for the request to be processed.

Who completes Sections F–G and where are those sections located?

Sections F–G are for non-medical change of status and change of PCS provider requests, completed by the beneficiary, family member, legal guardian, home care provider, or residential provider on page 3 of the form.

Sep 19, 2026

Upload by Felix Montgomery