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NC DHB-3051: PCS Attestation of Medical Need

North Carolina Medicaid requires this request and practitioner attestation before NC LIFTSS, the independent assessment entity, assesses a beneficiary for Personal Care Services (PCS). The practitioner lists the diagnoses and ICD-10 codes that cause the need for help with bathing, dressing, toileting, eating or mobility. It covers new requests, medical change of status and managed care disenrollment.

Who completes it

The beneficiary's primary care practitioner or inpatient practitioner completes and signs pages 1 and 2 (Sections A to E); without a PCP, the practitioner treating the limiting condition may sign. Page 3, for non-medical changes and provider changes, is completed by the beneficiary, family, guardian or PCS provider.

Submitting and payment

How to submit it
Fax the completed form to NC LIFTSS (Acentra Health), using the separate expedited assessment fax line when an expedited assessment is needed. Managed care disenrollment requests must reach NC LIFTSS before the disenrollment date.

Good to know

  • The date of the practitioner's last visit must be less than 90 days before NC LIFTSS receives the form, and signature stamps are not allowed, though a practice stamp is.
  • Every diagnosis needs a complete ICD-10 code and must relate to the ADL deficit for the request to be processed.
  • The optional attestation lets the practitioner initial items such as increased supervision needs, dementia-trained caregivers, a modified safe environment and a history of wandering or falls.
  • Since 11/1/2018, beneficiaries referred to adult care homes licensed under G.S. 131D-2.4 need a Referral Screening ID (RSID) from an LME-MCO before a PCS assessment.

Get the official form

Download the current version from the source each time; forms change without notice.

Request for Independent Assessment for Personal Care Services - Attestation of Medical Need

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign the NC DHB-3051?

The beneficiary's primary care practitioner or an inpatient practitioner must complete it. If the beneficiary has no PCP, the practitioner currently treating the medical, physical or cognitive condition causing the functional limitation may complete it. The practitioner signs with credentials; signature stamps are not allowed.

How recent must the visit be for DHB-3051?

The date of the beneficiary's last visit with the attesting practitioner must be less than 90 days from the date NC LIFTSS receives the form. The form prints this rule next to the visit date field in Section C and repeats it in the instructions for medical change of status requests.

What does Section D of DHB-3051 require?

Section D is required for every medical change of status request. The practitioner describes the specific medical change in condition and how it affects the beneficiary's need for hands-on assistance with activities of daily living. A medical change of status request without Section D is incomplete.