Forms For Medicaid Personal Care Services (PCS)
Forms on this page are in the PDF format unless noted. The free Adobe Acrobat Reader is required to view and print PDF files.
QiRePort Provider Registration For PCS Users
The Provider Interface is a secure, web-based information system called QiRePort that is managed by VieBridge, Inc. All PCS Providers are required to enroll in the Provider Interface. To register download the below form, complete, and send to Viebridge, Inc. following the directions in the form.
Request for Independent Assessment for Personal Care Services (PCS) Attestation of Medical Need - DMA 3051 (Effective 5/10/2019)
- Request for Independent Assessment Attestation of Medical Need - Form (DMA 3051)
- Request for Independent Assessment Attestation of Medical Need - Instructions
ICD-10 Transition Form (NC Medicaid 3137)
EPSDT Short Term Increase-In-Hours Request Form (NC Medicaid 3116)
**For beneficiaries under 21**
- Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form (NC Medicaid 3116)
- Instructions - Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form (NC Medicaid 3116)
Request for Reconsideration of PCS Authorization Form (NC Medicaid 3114)
- Request for Reconsideration of PCS Authorization Form (NC Medicaid 3114)
- Instructions - Request for Reconsideration of PCS Authorization Form (NC Medicaid 3114)
For more information on this new reconsideration process, please visit medicaid.ncdhhs.gov/providers/programs-and-services/long-term-care/personal-care-services/reconsideration-request.
Quality Improvement Attestation Form (NC Medicaid 3136)
Providers must submit Internal Quality Improvement Program Attestation (NC Medicaid 3136) Forms to Medicaid.PCSQualityImprovement@dhhs.nc.gov in order for Medicaid to receive and process the forms appropriately.
- Quality Improvement Attestation Form (NC Medicaid 3136)
- Instructions - Quality Improvement Attestation Form (NC Medicaid 3136)
SESSION LAW 2013-306 PCS TRAINING ATTESTATION FORM NC Medicaid-3085
- PCS Training Attestation Form - NC Medicaid 3085 (Effective 04/2019)
- PCS Training Attestation Form Instructions - NC Medicaid 3085 - Instructions (Effective 04/2019)
Providers must submit Session Law 2013-306 PCS Training Attestation NC Medicaid-3085 Forms to Medicaid.PCSTraining@dhhs.nc.gov in order for Medicaid to receive and process the forms appropriately.
The NC Medicaid 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. NC Medicaid PCS program committee requires that Providers attest to their aide training curriculum and submit the form to NC Medicaid for recordkeeping.
NC Medicaid Form 3051 Training Program
In partnership with NC Medicaid, we at Liberty Healthcare of North Carolina are committed to bringing you the best in training materials.
Please see our point-to-point training instructions on how to complete the NC Medicaid 3051 Personal Care Services form.