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MassHealth PCA PCP Summary Form

A member's primary care provider must fully complete and sign this two-page summary before a Personal Care Management (PCM) agency can evaluate the member for MassHealth personal care attendant services under 130 CMR 422.000. The PCP lists the diagnoses that limit activities of daily living, current medications, and complex care needs such as digital rectal stimulation or enteral tube feeding.

Who completes it

The PCM agency fills in Section A, the member and agency information. The member's PCP, a medical doctor, nurse practitioner or physician assistant, completes Sections B to E and signs the attestation.

Submitting and payment

How to submit it
Return the signed form to the PCM agency named in Section A, which uses it in its assessment of medical necessity for PCA services.

Good to know

  • Section B asks only for diagnoses that affect function and prevent independent ADLs and IADLs, each with an onset date. Section C lists all current medications, or attach a medication list.
  • If the member needs digital rectal stimulation or enteral tube feeding, the PCP must summarize the need for help with those tasks and give the diagnoses and ICD-10 codes.
  • MassHealth does not approve skilled care by a PCA. Tube feeding for a member at aspiration risk may be done only by a health care professional, parent or legal guardian.
  • Sign according to MassHealth All Provider Bulletin 385, with your NPI or MassHealth provider ID. The current version is PCA-PCP-1, dated June 2025.

Get the official form

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

MassHealth Personal Care Attendant PCP Summary Form

Official pagePDF

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 MassHealth PCA PCP Summary Form?

The member's primary care provider, who may be a medical doctor, nurse practitioner or physician assistant. The PCP must fully complete Sections B to E, including diagnoses, medications and complex care needs, and sign the attestation that the information and any attachments are true and complete.

Where do I send the PCA PCP Summary Form?

To the Personal Care Management agency listed in Section A, which is evaluating the member for personal care attendant services. The agency fills in the member details before sending it to the PCP and uses the completed summary in its own assessment of medical necessity.

What complex care needs does the PCA PCP summary ask about?

Section D asks whether the member needs digital rectal stimulation or feeding through a gastrostomy or jejunostomy tube, whether a caregiver must help, whether the member is at risk of aspiration, and whether tube feeding by someone other than a skilled caregiver is clinically appropriate.