Call (612) 345-4490
For case managers and referral sources

Referral form: PCA/CFSS and 245D waiver services

Send us a participant. Complete what you have, and we will follow up on anything missing. We respond within one business day with a clear yes or no on staffing.

Start the referral → (612) 345-4490
ALLCARE LLC
Referral Form · PCA/CFSS and 245D Waiver Services
2304 Park Ave, Suite 126
Minneapolis, MN 55404
(612) 345-4490
info@allcaremsp.com

Referral form

Nothing is sent from this page. Fill in the form, then choose Save as PDF. Your answers stay on your computer. Send the saved file to ALLCARE by secure email, fax, or hand delivery. Because it contains health information, do not send it by regular email.
Referral Source
1Participant Information
2Service Request Type

Check all that apply.

Personal Care Assistance (PCA) / Community First Services & Supports (CFSS)

Assessment required for ADL/IADL support and health-related procedures.

245D Waiver Services

If you check any of these, describe the specific needs in Section 3.

3Functional Needs & Behavioral Support

Critical for 245D. Funders generally require specific functional limitations that make the service necessary.

4Health & Safety
5Current Support Team
6Authorization

I authorize the release of information necessary for service determination and consent to the assessment process. I understand that this is a referral for evaluation only and does not guarantee service authorization.

Call to confirm fax or secure email

In the window that opens, set the destination to Save as PDF (or choose a printer to fax a paper copy). Then send it to info@allcaremsp.com by secure email, or hand deliver it to 2304 Park Ave, Suite 126, Minneapolis.

Signature (participant or representative)
Date
Getting it right the first time

Tips for an effective referral

What most often sends a referral back for more information.

Be specific about functional limitations

For 245D waiver services, funders generally require the specific functional limitations that make the service necessary. Section 3 is where that gets decided, so vague answers there tend to come back as questions.

Include what works, not just what goes wrong

If the referral is for night supervision or respite because of high behavioral needs, include the de-escalation techniques and positive support strategies that already work for this person. It shortens onboarding and prevents avoidable crises.

Remember the assessments are separate

PCA and CFSS usually require their own assessment, while the 245D services here typically run through a MnCHOICES or 245D functional assessment. Checking both on one referral does not merge the two processes.

Questions before you send it?

Call (612) 345-4490 and describe the situation. We will tell you honestly whether we can staff it before you fill anything out.

(612) 345-4490 For case managers