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Get PERSONAL CARE SERVICES PLAN - Nd

T First Medicaid Number Middle Address County of Residence City State Section II - Personal Care Services Eligibility ADL Scoring (An impairment is 2 or 3) 0 Completely able 1 Able with aids/difficulty 3 Unable Meal Preparation Qualifies for: PCS - A Date of Comprehensive Assessment Bathing Continence B/B Transfers/Bed/Chair 2 Able with help IADL Scoring (An impairment is 1 or 2) Zip Code Eating Dressing Toileting Mobility Inside 0 Without help; 1 With help; 2 Can.

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