Physician Referral Form
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
Liberty Healthcare Corporation - NC
Facility, Home, and Community Based Services