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Assessing Eligibility for the North Carolina Medicaid Personal Care Services

Forms For Medicaid Personal Care Services (PCS)

Attention PCS Providers - Internal Quality Improvement Attestation Forms (DMA 3136) must be submitted to DMA by December 31, 2016. Completed ICD-10 Transition Forms (DMA 3137) must be submitted to Liberty Healthcare Corporation by January 30, 2017.

Forms on this page are in the PDF format unless noted. The free Adobe Acrobat Reader is required to view and print PDF files.

Short Term Increase-In-Hours Request Form (DMA 3116)

Request for Reconsideration of PCS Authorization Form (DMA 3114)

For more information on this new reconsideration process, please visit

ICD-10 Transition Form (DMA 3137)

Quality Improvement Attestation Form (DMA 3136)

Request for Independent Assessment for Personal Care Services (PCS) - DMA 3051 (Effective 10/1/2015)

Request For Additional Hours of PCS
Due to Alzheimers or other Memory Care Complications

The DMA 3085 form was created based on Session Law 2013-306. Providers serving beneficiaries seeking additional hours of PCS due to Alzheimers or other Memory Care complications are required to have caregivers with training or experience in caring for individuals who have a degenerative disease characterized by irreversible memory dysfunction that attacks the brain and results in impaired memory, thinking, and behavior, including gradual memory loss, impaired judgment, disorientation, personality change, difficulty learning, and the loss of language skills. The NC DMA PCS program committee requires that Providers attest to their aide training curriculum and submit the form to DMA for recordkeeping.

DMA Form 3051 Training Program

In partnership with the Division of Medical Assistance, we at Liberty Healthcare of North Carolina re committed to bringing you the best in training materials.

Please see our point-to-point training instructions on how to complete the DMA 3051 Personal Care Services form.

PCS News & Resources

NC Division of Medical Assistance (DMA)

Medicaid's Personal Care Services


Important Notes

Incomplete Forms will be returned to the referring entity via fax with a request for required missing information. PCS eligibility assessments will not be scheduled until all required Referral information is complete.