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Approved, SCAN IS CODE: VSL STATEMENT OF SERVICES PERFORMED BY ATTORNEY 7-DAY 21-DAY STATE OF MICHIGAN JUDICIAL CIRCUIT FAMILY DIVISION COUNTY In the matter of adopted FILE NO. DOB: Full name of child

How to fill out pca346 statement of services

How to fill out PCA346 Statement of Services:

1. Start by downloading the PCA346 Statement of Services form from the relevant government website. This form is typically used for reporting services provided by personal care assistants (PCAs) to Medicaid beneficiaries.
2. Begin by providing your personal information in the designated sections of the form. This includes your name, address, phone number, and any other required details.
3. Next, you will need to enter the information of the Medicaid beneficiary for whom you provided services. This includes their name, Medicaid ID, and any relevant contact information.
4. In the "Service Dates" section, record the specific dates on which you provided services to the Medicaid beneficiary. Make sure to accurately document the start and end dates of each service period.
5. For each service date, indicate the type of service provided. This can include personal care, meal preparation, medication assistance, housekeeping, transportation, or any other services you offered as a PCA.
6. In the "Hours" column, record the number of hours you worked for each service date. Ensure that these hours align with the services provided.
7. Calculate the total number of hours worked for each service category and enter the totals in the respective sections at the bottom of the form.
8. Sign and date the form, attesting to the accuracy of the information provided.
9. Keep a copy of the completed PCA346 Statement of Services for your records, and submit the original form to the appropriate authority as instructed. This may involve mailing it or submitting it electronically, depending on the requirements in your area.

Who needs PCA346 Statement of Services?

1. People who provide personal care services to Medicaid beneficiaries may need to complete the PCA346 Statement of Services. This includes personal care assistants (PCAs) who are contracted or employed to provide essential support to individuals who receive Medicaid benefits.
2. Medicaid beneficiaries who require personal care services may also need the PCA346 Statement of Services for documentation and reporting purposes.
3. Additionally, government agencies, healthcare providers, or insurance companies involved in Medicaid programs might request the PCA346 Statement of Services to ensure accurate billing and reimbursement.

Note:

The specific requirements for filling out the PCA346 Statement of Services may vary depending on the jurisdiction and Medicaid program regulations. It is crucial to follow the instructions provided with the form and consult any additional guidelines or resources relevant to your situation.

For pdfFiller’s FAQs

What is pca346 statement of services?

The pca346 statement of services is a form used to report the services provided by a personal care assistant (PCA) to a client.

Who is required to file pca346 statement of services?

PCAs are required to file the pca346 statement of services for each client they provide services to.

How to fill out pca346 statement of services?

To fill out the pca346 statement of services, PCAs need to provide details about the services they provided to the client, including the dates and types of services.

What is the purpose of pca346 statement of services?

The purpose of the pca346 statement of services is to document the services provided by PCAs to ensure proper billing and payment.

What information must be reported on pca346 statement of services?

The pca346 statement of services must include details such as the client's name, dates of service, types of services provided, and any additional notes.

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