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Assessing Eligibility for the North Carolina Medicaid Personal Care Services

Medicaid
PCS
News

New DMA-3051
Physician Referral Form
Effective 2/2/15

January 29, 2015

Attention: PCS Beneficiaries, Providers and Physicians

Effective February 2, 2015, beneficiaries requesting Personal Care Services (PCS) must use the new DMA 3051 - Request for Independent Assessment for Personal Care Services (PCS) Attestation of Medical Need (2/2/2015) form. This is a revised version of DMA 3051- Request for Services Form (12/1/2013).

DMA-3051 Request for Services Form (12/1/2013) will not be processed if submitted on or after February 2, 2015. Instruction and training about how to complete the new form were provided prior to Feb. 2, 2015. Providers must adhere to the dictates of those instructions and trainings.

New forms, instructions, and training materials will be available here:

For questions regarding the new form, contact the N.C. Division of Medical Assistance - PCS Program or Liberty Healthcare Corporation - NC

N.C. Division of Medical Assistance - PCS
919-855-4360
E-Mail: PCS_Program_Questions@dhhs.nc.gov

Liberty Healthcare Corporation - NC
1-919-322-5944
1-855-740-1400
E-Mail: NC-IAsupport@libertyhealth.com

Facility, Home, and Community Based Services
DMA, 919-855-4360



Call Center Information

Phone: 1-919-322-5944
        Or  1-855-740-1400
Fax: 1-919-307-8307
        Or  1-855-740-1600
E-Mail: NC-IAsupport@libertyhealth.com