Liberty Healthcare Logo
 
Questions? Call 1-919-322-5944
                        1-855-740-1400
Assessing Eligibility for the North Carolina Medicaid Personal Care Services

Medical Providers
DMA 3051 Form
Instructions

Doctor talking with elderly patient

How To Complete DMA 3051 Request For Services Form

The Personal Care Services (PCS) DMA 3051 Request for Services form is a multi-section form. It contains separate sections for a New Referral Request, a Change of Status Request, a Change of Provider Request and the Request for Additional Hours.

A. Who Is Authorized To Sign?

The Request For Services Form must be signed by the patient's referring entity: that is, his or her doctor, nurse practitioner or physician's assistant.

B. What Sections Do The Medical Provider Need To Complete & Sign?

As the medical provider for your Medicaid patient, you're asked to complete and sign the DMA 3051 form for the New Referral section and, if appropriate for your patient, the Request for Additional Hours section.

Note: The DMA 3051 is the only form that will allow medical providers to provide written attestation to the medical necessity for up to 50 additional PCS hours.

C. Downloadable Instructions

The DMA 3051 Form instructions are offered online in pdf format. Please download the free Adobe PDF Reader. For your convenience, we offer the instructions in both full color and in black-and-white.

COLOR BLACK & WHITE
  New Referral Requests   New Referral Requests
  Request for Additional Hours   Request for Additional Hours

Reasons why a Request For Services may be denied, i.e., missing a signature.
  Technical Denials   Technical Denials

How to expedite a request for a nurse assessor's review of your patient.
  Expedited Assessments   Expedited Assessments

You may also be interested in reviewing the following materials.
  Overview Of Form   Overview Of Form
  Change of Status   Change of Status
  Change of Provider   Change of Provider

For any questions concerning the DMA 3051, please contact Liberty Customer Support at 1-919-322-5944 or 1-855-740-1400.

For Questions Concerning the Request For Services Form

Phone: 1-919-322-5944
        Or  1-855-740-1400
Fax: 1-484-434-1571
        Or  1-855-740-1600
E-Mail: NCfax@libertyhealth.com

Mailing Address:
Liberty Healthcare Corporation of NC
Attn: Referral Processing Department
5540 Centerview Drive, Suite 114
Raleigh, NC 27606

For New Referral Requests:

  • Complete Sections A, B & C
  • Sign Section C
  • Fax or Mail Page One of the completed form.

For Additional Hours Requests For New Referrals:

  • Complete Sections A, B, C and E
  • Sign Sections C & E
  • Fax or Mail Page One and Two
    of the completed form.

For Additional Hours Requests For Current Beneficiaries:

  • Complete Sections A, B, C, D
    and E
  • Sign Sections C & E
  • Fax or Mail Page One and Two
    of the completed form.