EPSDT PCS Plan of Care                                        Online Form
Click to view/print the EPSDT Plan of Care Form

Type of Plan of Care

Check the appropriate box to identify the Plan of Care:

  • New - Used for an agency’s initial Plan of Care for beneficiary
  • Renewal - Used for Plan of Care completed for each new authorization period
  • Reconsideration - Used when the Plan of Care changes during the authorization period

Date Services Requested to Start

Complete with the date the provider agency is requesting to start providing services.

Identifying Information

  • Name - Beneficiary’s name
  • ID# - Medicaid beneficiary number
  • DOB - Beneficiary’s date of birth
  • Address - Beneficiary’s address (street and city)
  • Home Phone# - Beneficiary’s home phone number
  • Cell Phone # - Beneficiary’s cell phone number

Provider Information

  • Provider Agency Name - Name of the provider agency requesting authorization
  • Provider Number Provider agency's assigned Medicaid provider number
  • Provider Phone Number - Phone number of provider agency
  • Address - Provider agency's mailing address (street, city and ZIP Code)
  • Contact person, e-mail and Phone # - Name of provider agency's representative and e-mail address

Medical Reasons Supporting the Need for PCS

Summarize the beneficiary's medical condition. and provide medical documentation from his/her physician that includes this individual's functional limitations.

Other In-Home Services Requested or Currently Receiving

Identify all in-home services the beneficiary is currently receiving or has requested.

Personal Care Tasks

For the personal care tasks of "Bathing", "Dressing", "Grooming", "Toileting", "Eating", "Meal Prep" and "Incidental Household Services" that the beneficiary requires assistance with because of his/her disability, complete the following:

  • Goal - include the goal for the personal care task
  • # of Days Requested per Week - indicate the number of days during the week assistance is being requested with the personal care task
  • Time Requested to Complete Activity - indicate the time required in minutes to complete the activity, (i.e., 15 minutes, 30 minutes, etc.)
  • Total Time Requested for Week - indicate the total time requested for the week by multiplying the number of days the service is requested by the time requested to complete the activity to obtain the total time needed each week to complete the task, (i.e., 1 hour 15 minutes, 3 hours 30 minutes, etc.)
  • Total Weekly Hours Requested for Activities of Daily Living - add the Total Time Requested for Week for each PCS Activity to obtain the total time requested for the week to complete the covered personal care tasks

 

For the personal care task of -Accompanying to Medical Appointments-, complete the following when it is medically necessary that someone accompany the beneficiary and his/her caregiver to medical appointments:

 

-        Goal - include the goal for the personal care task

-        Frequency of Medical Appointments - indicate the frequency the beneficiary typically has medical appointments within the prior authorization period, (i.e., weekly appointment, monthly appointment, etc.)

-        Time per Trip - indicate the time it typically takes the beneficiary to complete the medical appointment, (i.e., 1 hour, 2 hours, etc.)

Signatures

A signature and date from the parent/guardian, the provider and the physician are required.