The Minnesota Department of Human Services (DHS) provides a collection of forms related to the Personal Care Assistance (PCA) Program. These forms are essential for lead agencies, PCA providers, and consumers to facilitate various administrative and service-related processes within the PCA program.

Available Forms:

• Lead Agency Forms:

  • Communication to Physician of PCA Services (DHS-4690): Used to inform physicians about PCA services provided to a client.

  • PCA Assessment and Service Plan (DHS-3244): Documents the assessment and outlines the service plan for PCA recipients.

  • Referral for Reassessment for PCA Services (DHS-3244P): Initiates a reassessment process for existing PCA services.

• PCA Provider Forms:

  • MHCP Organization – Provider Profile Change (DHS-3535A): Notifies DHS of changes in provider information.

  • PCA Time and Activity Documentation (DHS-4691): Records the time and activities performed by PCAs for billing and compliance purposes.

  • MHCP PCA Program Responsible Party Agreement and Plan (DHS-5856): Establishes the agreement and plan between the responsible party and the PCA program.

• PCA Provider Enrollment Forms:

  • Individual PCA Enrollment Application (DHS-4469): Application form for individuals seeking to enroll as PCA providers.

  • MHCP Provider Agreement Individual Support Worker (DHS-4611): Agreement outlining the terms for individual support workers within the PCA program.

  • MHCP PCA Agency Surety Bond (DHS-6033): Required surety bond documentation for PCA agencies.

• PCA Consumer Forms:

  • Appeal to State Agency (DHS-0033): Allows consumers to appeal decisions related to PCA services.

  • MHCP Change Report Form (DHS-4796): Used by consumers to report changes that may affect their PCA services.

  • Civil Rights Complaint Form: Discrimination in Service Delivery (DHS-2807): Enables consumers to file complaints regarding discrimination in service delivery.

These forms are integral to the administration and delivery of PCA services, ensuring proper documentation, compliance, and communication among all parties involved.

For a complete list of PCA-related forms and detailed information, visit the DHS PCA Forms page:

🔗 PCA Forms