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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 (normal and expedited), a Change of Status Request, a Change of Provider Request and the Request for Additional Hours. Basic guidelines for completing each section are outlined on the page below.

The DMA 3051 form with detailed instructions is available by clicking on the following link:  Request for Services Form and Instructions - DMA 3051 (Effective 10/1/2015)

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.

Completing PCS Form DMA 3051

For New Referral Requests

  • Sections A, B, and C must be completed by the Medical Practitioner.
  • All fields are required and if incomplete, may result in request processing delays. 
  • Ensure all sections are clear and legible.
  • Optional Attestation for additional hours must be initialed if applicable. Check marks, X’s and typed initials are not accepted.
  • Section C must include referring practitioner signature and credentials.  Signature stamps are not accepted.

For Change of Status Medical

  • Sections A, B, C and D must be completed by the Medical Practitioner.
  • Follow same guidelines above for New Referral Requests.
  • Section D must detail the change in medical condition which results in a need for increased or decreased hours of PCS.

Submitting PCS DMA FORM 3051

  • Complete all appropriate sections     
    • Practitioners submit pages 1&2 of the 3051 form
  • Fax the completed form to: 919-307-8307 or 855-740-1600 (toll free)
  • If preferred, forms can be mailed to:

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

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

Resources and Helpful Links

How to Expedite a Request

Expedited Assessment Training

Referring Physician Training DMA Form 3051

Medical Change of Status Training

Physician Attestation and What That Means to You