How to Complete the DHB 3051 Form: NC Medicaid Personal Care Services

The DHB 3051 form is the request a North Carolina practitioner submits to start an independent assessment for Medicaid Personal Care Services (PCS). A treating practitioner fills out the beneficiary’s identifying information, medical diagnoses with ICD-10 codes, functional ratings for each activity of daily living, and a signed attestation, then faxes the completed form to NC LIFTSS at 1-833-521-2626. Submission does not approve services on its own; it triggers an in-person assessment that decides eligibility and monthly hours.¹

Who Should Complete the Form

The beneficiary’s primary care provider or the inpatient practitioner currently treating them should complete the DHB 3051. If the person has no primary care provider, any practitioner treating the condition that causes the functional limitations can fill it out instead.² The practitioner is attesting under their own credentials that a documented medical condition is causing hands-on functional limitations, so the information on the form has to match what is in the chart.

Filling Out Each Section

Beneficiary Identification

Enter the beneficiary’s full legal name exactly as it appears on their Medicaid card, along with their date of birth and Medicaid ID number. Even a minor spelling difference from the Medicaid card can delay processing because the system cannot match the request to the eligibility file.²

Diagnoses and ICD-10 Codes

List the primary diagnosis and any secondary diagnoses with the matching ICD-10 codes. Both the written diagnosis and the code are required, and each diagnosis has to connect to the ADL deficit being documented. Diabetes on its own would not support a request for bathing help; neuropathy causing balance problems would.²

Activities of Daily Living

Rate the person’s current functional level for each of the five ADLs North Carolina recognizes: eating, dressing, bathing, toileting, and mobility within the home.¹ The scale runs from fully independent to fully dependent:

Totally Able: the person can do the activity on their own, with or without assistive devices.
Verbal Cueing or Supervision: the person performs the task but needs reminders, monitoring, or help setting up.
Limited Hands-On Assist: the person can do roughly half the task and needs physical help to finish.
Extensive Hands-On Assist: the person can do less than half and needs hands-on help for the majority.
Cannot Do At All: the person is completely dependent on someone else for that activity.

Only ratings of Limited Hands-On Assist or higher count toward qualification. Cueing and supervision alone do not. The ratings you record should match what is already in recent medical records, including hospital discharge summaries, progress notes, and therapy evaluations, because an assessor will later compare the form against what they observe in person.

Practitioner Certification

Sign and date the attestation section. Signature stamps are not accepted.² Fill in complete practice information: name, NPI, address, and phone number. An incomplete practitioner block is one of the most common reasons a form comes back.

What the Ratings Need to Show

For the request to lead to an approval, the ADL ratings on the form have to meet one of three thresholds:¹

Three ADLs at the limited hands-on level or higher.
Two ADLs with at least one at the extensive hands-on level.
Two ADLs with at least one at full dependence.

If the clinical picture does not reach one of these combinations, the independent assessment will not find eligibility, no matter how clearly the form is completed.

Where to Get the Form and How to Submit It

Download the current DHB 3051 from the North Carolina Division of Health Benefits at medicaid.ncdhhs.gov.³ It is also posted on the Adult Care Home and Personal Care Services Forms page.⁴ County Departments of Social Services, hospital discharge planners, and admitting care facilities often keep copies.

Confirm the version before you send. As of April 1, 2025, only the September 2024 or later version is accepted; submitting an older version delays processing until the provider corrects and resubmits.¹ Fax the completed form to NC LIFTSS at 1-833-521-2626 (toll free). NC LIFTSS is the state-contracted entity that processes PCS requests and schedules the assessments.

What Happens After You Submit

Once NC LIFTSS receives the form, NC Medicaid or its designated assessor schedules an independent assessment of the beneficiary.¹ The assessor evaluates functional abilities firsthand, looks at the living environment, and compares what they see to the practitioner’s attestation. Based on that visit, Medicaid decides whether the person qualifies and, if so, builds an individualized service plan with a monthly hour authorization. Approval and denial notices go to both the beneficiary and the PCS provider; a denial explains the reasons and the appeal rights.

Asking for More Than 80 Hours Per Month

The standard PCS authorization caps at 80 hours per month. The DHB 3051 includes a physician attestation for enhanced hours, and all four of these conditions must apply:

The beneficiary requires an increased level of supervision.
The beneficiary needs caregivers with training or experience in caring for people with a degenerative disease.
The beneficiary’s physical environment requires modifications and safety measures.
The beneficiary has a history of safety concerns related to wandering, ingestion of harmful substances, aggressive behavior, or frequent falls.

Three out of four does not qualify. The attestation is reviewed during the independent assessment along with the rest of the form.

If the Request Is Denied

A denial can be appealed through a State Fair Hearing with the North Carolina Office of Administrative Hearings. The request must be filed within 120 days of the date on the denial notice. If the person is already receiving PCS and the state proposes to reduce or terminate hours, services can continue at the current level during the appeal, but only if the request is filed within the advance notice period stated in the reduction letter.

Accuracy of the Attestation

Fabricating diagnoses, overstating functional limitations, or forging a practitioner’s signature on the DHB 3051 is Medicaid fraud. The federal False Claims Act imposes civil penalties of $14,308 to $28,619 per false claim, plus up to three times what Medicaid paid as a result.⁵ A practitioner who certifies false information also risks losing Medicaid provider enrollment and their professional license. The form is a sworn clinical attestation, and the ratings on it should reflect what the chart and the patient actually show.

1
NC Medicaid. Personal Care Services (PCS)
2
Partners Behavioral Health Management. DHB-3051 Request for Independent Assessment for Personal Care Services Attestation of Medical Need
3
NC Medicaid. Request for Services and Instructions (DHB 3051)
4
North Carolina Medicaid. Adult Care Home and Personal Care Services Forms
5
Federal Register. Civil Monetary Penalties Inflation Adjustments for 2025