North Carolina Medicaid uses this two-page physician request to start or continue private duty nursing (PDN) for a beneficiary. It documents diagnosis, prognosis, hours requested, caregiver availability, ventilator, oxygen and tracheostomy needs, and a summary of the last certification period. The form is to be completed within 15 business days of the start of care date and submitted to NC Medicaid.
The attending physician prints their name, address and phone, then signs and dates the request. The PDN agency's provider number, NPI and taxonomy are recorded on the same form.
Download the current version from the source each time; forms change without notice.
Physician's Request Form for Private Duty Nursing
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The form instructs that it be completed within 15 business days of the start of care date and submitted to NC Medicaid. The requested start of care date is entered at the top, along with the payer, before the patient, technology and nursing sections.
Yes, but NCTracks says the preferred method for prior approval requests is online through the NCTracks Provider Portal. If the 3075 is mailed or faxed, it must be the top page with any attachments, such as the 3061 referral or 3062 medical update, placed behind it.
The attending physician. The final block asks for the physician's printed name, address and phone number, signature and date. Item 26 also names the current attending physician, and item 29 the date of the last examination by an MD.