The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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The value you provided must be within the suggested range

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

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Required format:

PCCP Request Form

NOTICE: Due to the increased volume of requests, all communication from DSDS will be directed to the email address provided, unless a call is warranted. Please ensure you are checking your email address for the latest information related to your request.

Hello and welcome to the DSDS Online PCCP Request Form!

The PCCP Request Form is used to request changes to HCBS care plans for active participants receiving State Plan Services, Aged & Disabled Waiver services, Adult Day Care Waiver services, or Independent Living Waiver services administered by the Division of Senior and Disability Services.

Note: This form is to be used for individuals who are currently receiving HCBS through DSDS. Please refer to the Online HCBS Referral Form to submit a new referral for services.

Note: It is illegal in the State of Missouri to willfully provide false information in an attempt to obtain any public assistance benefits, programs, and services. Any person who willfully provides false information in an attempt to obtain any public assistance benefits, programs, and services shall be guilty of the crime of stealing. Please reference Missouri Statue 205.967 for more information.

Note: Incomplete submissions will not be processed, please complete the entire form.

Participant First Name

* must provide value

Participant Last Name

* must provide value

Participant DCN

* must provide value

Participant Date of Birth

* must provide value

M-D-Y

Participant Address (Line 1)

* must provide value

Participant Address (Line 2)

Participant City

* must provide value

Participant County

* must provide value

Participant Zip Code

* must provide value

Participant Contact Number

* must provide value

Participant Alternate Contact Number

Participant E-Mail

Does the participant have a legal guardian / representative?

* must provide value

Yes

reset

Legal Guardian / Representative Name

* must provide value

Legal Guardian / Representative Contact Number

* must provide value

Legal Guardian / Representative E-Mail

Select Task:

Personal Care Task Comments

* must provide value

Expand

Select Task:

Advanced Personal Care Task Comments

* must provide value

Expand

Select Task:

Authorized Nurse Visit Comments

* must provide value

Expand

Select Task:

Consumer Directed Services Task Comments

* must provide value

Expand

Select Task:

Waiver Service Task Comments

* must provide value

Expand

HCBS Closing Requested

Medicaid Ineligible

Moved out of State

Non-Compliant

Nursing Facility Admission

Participant Died

Unable to Locate

reset

Is the participant's new address known?

* must provide value

Yes

reset

Participant's New Address (Line 1)

* must provide value

Participant's New Address (Line 2)

Participant's New City

* must provide value

Participant's New County

* must provide value

Participant's New Zip Code

* must provide value

Closing Requested - Non-Compliant
Please provide additional information

* must provide value

Expand

Anticipated Closing Date

M-D-Y

Other Request(s)

21-Day Notice

Provider Change

Switch to Consumer Directed Services (CDS)

Switch to Personal Care (IHS)

Switch to Residential Care / Assisted Living Facility (RCF/ALF)

Anticipated Closing Date (21-Day Notice)

M-D-Y

21-Day Notice Reason

Please ensure a copy of the 21-Day Notice is uploaded to the participant's case record in Web Tool.

* must provide value

Expand

Provider Change
Please provide additional information

Examples:
Participant requests new provider;
Provider unable/unwilling to continue services;
Participant moved out of service area; or
Unable to self-direct.

* must provide value

Expand

New Provider Name

New Provider Phone Number

Has the new provider accepted the participant?

Yes

reset

Tentative Start Date (Pending DSDS Approval)

M-D-Y

Does the participant need a provider list?

* must provide value

Yes

reset

Details of Request / Additional Information

* Do not submit information pertaining to Abuse, Neglect, or Exploitation in this form.
* Please submit this information via the Online Reporting Application.

Expand

Submitter Type

* must provide value

Self-Referral

Friends & Family

Provider Agency

reset

Submitter Name

* must provide value

Submitter Contact Number

* must provide value

Submitter E-Mail

I, the submitter, attest that I have spoken with the participant identified in this request, the participant has requested the changes outlined herein, and that the participant has authorized me to submit this request and to coordinate their person centered care planning change(s).

* must provide value

Add signature

Provider Agency Name

* must provide value

Provider Agency Contact Person

* must provide value

Provider Agency Contact Number

* must provide value

Provider Agency E-Mail

* must provide value

Add signature

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