Form Dma-3087 - Service Request For Home And Community-Based Services Physician Attestation - North Carolina

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NC DMA Long-Term Services and Supports authorization of Level of Care
Service Request for Home and Community-Based Services Physician Attestation
This form is to verify that the assessment of medical, functional, psychosocial and behavioral
health needs identified in the Service Request Form (SRF) for the listed individual are consistent
with nursing facility level of care criteria. Based on this verification, this individual is considered
medically stable to participate in a home and community based program.
Beneficiary Information:
Name: _____________________________________
MID #: _____________________________________
Primary Diagnoses (list attached): __ Yes
__No
Medication list attached:
__ Yes
__No
Physician’s Name: ______________________
Physician’s Address:_________________________________________________
____________________________
_____________________
Physician Signature
Date Attestation
Return this form to: ______________________________________
Contact Information: _____________________________________
For CSC/NCTracks Use Only:
Prior Approval Level of Care (LOC) Determination for A31 Community Alternatives Program (CAP) Children (CAP/C) or Disabled Adults
(CAP/DA or CAP/Choice)
The Community Alternatives Program is a Medicaid Home and Community–Based Services
(HCBS) Waiver authorized under § 1915(c) of the Social Security Act, found in 42 CFR440.180.
Federal regulations for HCBS waivers may be found in 42 CFR Part 441 Subpart G. The CAP
program waives certain NC Medicaid requirements to furnish an array of home and community
based services to children and adults with medical and physical disabilities who are at risk of
institutionalization. The services are designed to provide an alternative to institutionalization for
beneficiaries in this target population who prefer to remain in their primary private residences,
and would be at risk of institutionalization without these services.
DMA-3087
5/30/2014

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