NCDHHS Policies and Manuals

Title
DHB-1061 Checklist for Child Medical Evaluation (CME) Reporting
DHB-2039 PHP Notification of Nursing Facility Level of Care
DHB-2040 Tribal and Indian Health Services
DHB-2040B Tribal and Indian Health Services
DHB-2043 Third Party Recovery Accident Information Form
DHB-2044ia Medicaid Credit Balance Report
DHB-2045 Instructions for Completing Medicaid Credit Balance Report
DHB-2050 Voluntary Request to Terminate Medicaid
DHB-2050esp-ia SOLICITUD VOLUNTARIA PARA FINALIZAR MEDICAID
DHB-2055 Reimbursement for Medical Transportation
DHB-2056 Purchased Medical Transportation Costs
DHB-2060 Request To Leave Transitions To Community Living (TCL)
DHB-2190 Internal Inspection Report
DHB-2191 Designation of Control Officer for FRR/Beer Reports
DHB-2192 SSA Training Form – County Staff and County Contract Staff
DHB-2193 Memorandum of CAP Waiver Enrollment
DHB-2194 IRC Rules Handout
DHB-2195 Documentation of Annual Security Training Confidentiality Form – County Staff
DHB-2196 Documentation of Annual Security Training – Shred Contractor Training
DHB-2197 FTI Record Keeping Log
DHB-2198 Log for Destruction of the FRR/BEER Reports
DHB-2199 Documentation of the Visitation Logs
DHB-2200 Access Control Log
DHB-2201 Confidentiality of Safeguard Data
DHB-2202 Beneficiary Notice
DHB-4037 Disability Determination Transmittal
DHB-5001N FRENCH AVIS SUR L’UTILISATION DES NUMÉROS DE SÉCURITÉ SOCIALE
DHB-5001N Notice on the Use of Social Security Numbers
DHB-5001N_sp AVISO SOBRE EL USO DE LOS N√öMEROS DE SEGURO SOCIAL
DHB-5002 Important Notice About Your Medicaid or Special Assistance Approval
DHB-5002sp-ia Lea Este Importante Aviso Sobre Medicail o la Asistencia Especial Aviso de Aprobacion
DHB-5003 French VEUILLEZ LIRE CET AVIS IMPORTANT CONCERNANT VOTRE AVIS D’APPROBATION POUR MEDICAID
DHB-5003 Korean 귀하의 MEDICAID 승인 통지서와 관련된 본 중요 공지사항을 읽어주십시오
DHB-5003 Medicaid Approval Notice
DHB-5003-ia RUSSIAN ОЗНАКОМЬТЕСЬ С ЭТИМ ВАЖНЫМ УВЕДОМЛЕНИЕМ ОБ ИЗВЕЩЕНИИ О ПОДТВЕРЖДЕНИИ ПРОГРАММЫ MEDICAID
DHB-5003sp-ia LEA ESTE IMPORTANTE AVISO SOBRE MEDICAID AVISO DE APROBACION
DHB-5004-ia Buy-In Clerical Action
DHB-5008a Adult Budget Sheet
DHB-5008B Supplement B
DHB-5008c-ia Spouse and Dependent Income Allowance Worksheet
DHB-5008e ABD Medicaid Parent To Child Deeming Budgeting Sheet
DHB-5009 Social History Summary For The Disabled
DHB-5009esp-ia RESUMEN DE HISTORIA SOCIAL PARA PERSONAS CON DISCAPACIDADES
DHB-5016-ia Notification of Eligibility for Medicaid/Amount and Effective Date of Patient’s Liability
DHB-5024 Transportation Assessment Notification
DHB-5024sp Aviso de Evaluación de Transporte
DHB-5026 Notice Of Obligation To Apply For Veteran’s Benefits
DHB-5027 Veteran’s Benefits Verification Letter
DHB-5028-ia Authorization to Disclose Information
DHB-5028esp-ia AUTORIZACION PARA COMPARTIR INFORMACION
DHB-5036 Record Of Medical Expenses Applied To The Deductible
DHB-5043 Verification Form For Self-Employment Income and Expenses
DHB-5043-ia Verification Form For Self-Employment Income and Expenses
DHB-5046 Notice of Rights/Responsibilities – Medical Transportation Assistance (English & Spanish)
DHB-5046_Vietnamese HỖ TRỢ VẬN CHUYỂN Y TẾ NC THÔNG BÁO VỀ QUYỀNTRÁCH NHIỆM
DHB-5046Russian УВЕДОМЛЕНИЕ О ПРАВАХ/ОБЯЗАННОСТЯХ
DHB-5047 Medicaid Transportation Assessment
DHB-5048 Medicaid Transportation Exception Verification
DHB-5049-ia Referral to Local Social Security Office
DHB-5051 Estate Subject To Medicaid Recovery: Individuals Under Age 55
DHB-5051sp Notice of Medicaid Recovery – People Under 55 (Spanish)
DHB-5052 NOTICE: YOUR ESTATE IS SUBJECT TO MEDICAID RECOVERY
DHB-5052 sp AVISO IMPORTANTE SU PATRIMONIO EST√Å SUJETO A RECUPERACI√ìN DE MEDICAID
DHB-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice
DHB-5052SA-sp Notificación al Beneficiario de la Asistencia Especial Del Estado/Condado Sobre la Recuperación de los Gasto Médicos Pagados por Medicaid
DHB-5053 Estate Recovery – Permanently Institutionalized
DHB-5053sp SU PATRIMONIO EST√Å SUJETO A RECUPERACI√ìN DE MEDICAID
DHB-5054 Estate Recovery – Claim Notice
DHB-5054sp – Estate Recovery – Claim Notice (Spanish)
DHB-5056 Estate Recovery Information Form
DHB-5076 Pregnancy Management Program
DHB-5076 Pregnancy Management Program -Spanish Version
DHB-5078 Medicaid Transportation Monitoring Report
DHB-5079 Breast and Cervical Cancer Medicaid Application
dhb-5079sp Solicitud de Medicaid para c√°ncer de seno y de cuello uterino
dhb-5081-ia Breast and Cervical Cancer Verification: Screening, Diagnosis and Treatment
dhb-5081r-ia Breast and Cervical Cancer Recertification: Screening, Diagnosis and Treatment
dhb-5081r-sp-ia Para Seguir Recibiendo Cobertura De Medicaid Para El Cancer De Seno Y El Cancer Del Cuello Uterino
dhb-5081sp-ia Verificacion De Evaluacion, Diagnostico Y Tratamiento
dhb-5082 Transitional Benefit Report
DHB-5082sp INFORME SOBRE BENEFICIOS DE TRANSICIÓN
dhb-5083 Notice of Transitional Benefits
dhb-5083sp Aviso De Beneficios Transitorios
dhb-5084 Transitional Benefits Good Cause
dhb-5084sp Motivos Justificados Para No Haber Entregado A Tiempo Su Informe De Beneficios Transitorios
dhb-5087-ia Check List For Breast and Cervical Cancer Medicaid
dhb-5087-sp Check List For Breast and Cervical Cancer Medicaid
DHB-5095-ia Medicaid/Work First Notice of Inquiry
DHB-5095sp-ia Aviso De Indagacion Sobre Medicaid/Work First
DHB-5097 Request for Information
DHB-5097 Chinese 資訊請求
DHB-5097 Korean-ia 정보 요청
DHB-5097 Mon-Khmer Cambodian សំេណើសុំព័ត៌មាន
DHB-5097_Arabic طلب الحصول على معلوما ت
DHB-5097_Vietnamese Yêu cầu thông tin
DHB-5097Russian Запрос информации
DHB-5097sp-ia Solicitud de información
DHB-5098-ia Your Application for Medicaid is Pending
DHB-5104 Notice of Incomplete Application
DHB-5104sp Notificación de Solicitud Incompleta
DHB-5104Vietnamese Thông báo về đơn đăng ký không đầy đủ
dhb-5106 Medicaid Pace Program Referral
DHB-5111 Annuity Verification Form
DHB-5113, Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets)
DHB-5115 Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value)
DHB-5118A-ia Medicaid Transportation Verification of Receipt of Covered Service – A
DHB-5118B-ia Medicaid Transportation Verification of Receipt of Covered Service- B
DHB-5119 Denial of Transportation Request(s)
DHB-5119sp Negación de Solicitudes de Transporte
dhb-5121 Determining Potential Medicaid Eligibility
DHB-5122 Community Spouse Resource Protection Worksheet
DHB-5125 Medicaid Transportation No-Show Notice
DHB-5125a Medicaid Transportation No-Show Final Notice
DHB-5125Asp Aviso final: Usted no usó el transporte de Medicaid
DHB-5125B Medicaid Transportation Suspension Notice
DHB-5125Bsp Aviso de Suspensión de Transporte de Medicaid
DHB-5125sp Aviso: Usted no usó el transporte de Medicaid
DHB-5150A PASS-ALONG SCREENING GUIDE
DHB-5150B Screening for Medicaid Eligibility Under the COLA Pass-along
DHB-5152 North Carolina Residency Declaration
DHB-5152sp Declaración de residencia en Carolina del Norte
DHB-5161 Transfer of Asset Below Current Market Value
DHB-5164 Change to PML Request Memo
DHB-5165 PACE Referral Request For A Medicaid Hearing
DHB-5166 PACE Application Report
DHB-5170 Request for Claims Override
DHB-5175 Marriage Verification
dhb-5179 MAABD Eligibility Overview Chart
DHB-5181 5181 Calculating Penalty Period – Transfers 11/1/07 or Later
DHB-5200 Tagalog-ia Aplikasyon para sa Saklaw sa Kalusugan at Tulong sa Pagbabayad ng mga Gastos
DHB-5200 Vietnamese-ia Đơn đăng ký Bảo hiểm Y tế & Trợ giúp Thanh toán Chi phí
DHB-5200-ia Application for Health Coverage & Help Paying Costs
DHB-5200sp Solicitud Para Cobertura de Salud y Ayuda Para Pagar los Costos
DHB-5201-ia Application for Health Coverage & Help Paying Costs (Short Form)
DHB-5202 Vietnamese-ia PHỤ LỤC C – Chỉ định người đại diện được ủy quyền
DHB-5202C-ia Designation of Authorized Representative – Appendix C
DHB-5202E-ia Medical Bills – Appendix E
DHB-5202Esp-ia Apéndice E – Facturas médicas
DHB-7058 Investigative Summary
dhb-7059 Notice Of Change In Overpayment For Medical Assistance
dhb-7060 Voluntarty Repayment Agreement
dhb-7061 Voluntary Wage Withholding Agreement
dhb-7063 Medicaid/NC Health Choice Recipient Profile Request Sheet Apr 21, 2021
DHB-7078A Application 2nd Party Review Worksheet
DHB-7078R Recertification 2nd Party Review Worksheet
dhb-7097-ia Recipient Request and Authorization to Disclose Health Information
dhb-7098-I DMA-7098 – Additional Information and Instructions Feb 23, 2021
dhb-8010 Notice of Overpayment For Medical Assistance
dhb-8010sp Notice of Overpayment For Medical Assistance (Spanish Version)
DHB-8020-ia Medicaid Eligibility Corrections Form
DMA 9006sp Formulario de inscripción en CCNC/CA
dma-0100 Physician’s Signature for Authorization of Level of Care
dma-1049 Cover Letter for LIS Application for Medicaid
dma-1050 Notice of Application for Extra Help with Medicare Prescription Drug Costs
dma-1051 LIS Verification Checklist
dma-1051-ia LIS Verification Checklist
dma-1052 Notice of Approval for Extra Help with Medicaire Prescription Drug Costs
dma-1052-ia Notice of Approval for Extra Help with Medicare Prescription Drug Costs
dma-1053 Medicare Prescription Drug Subsidy Assistance
dma-1053-ia Medicare Prescription Drug Subsidy Assistance
dma-1054 Report of Approval/Denial of LIS Application
dma-2000a County DSS Request for DMA Forms
dma-2000h Health Agencies Request for DMA Forms
dma-2000x Order Form for NC Medicaid Consumer Guides
dma-2041-ia Third Party Recovery Insurance Information
dma-2046 Third Party Liability Medicaid and NC Health Choice Billing Guide
dma-2053-ia Insurance Company Code Request Form
dma-2057 Health Insurance Information Referral Form
dma-2069 Health Insurance Premium Payment Program Application
dma-2073 Medicaid Payment Information Request
dma-2073-I Instructions for Medicaid Payment Information Request
dma-2188 Notice of Privacy Practices
dma-2188sp Aviso De Pr√°cticas De Privacidad
dma-2190 Report of Internal Inspection FRR/BEER
dma-2191 Designation of Control Officer for FRR/BEER
dma-2192 Documentation of SSA Security Training
dma-3002 Program Care Coordinator Pregnancy Outcome Report
dma-3004 Maternity Care Coordination Letter of Agreement
dma-3005 Care Coordinator Appointment Record
dma-3006 Care Coordination Record
dma-3007-ia Family Care Coordination Plan
dma-3016 Care Coordination Narrative Sheet
dma-3019 Individual Authorization Form
dma-3047 Hysterectomy Statement Form
dma-3050R Adult Care Home Personal Care Physician
dma-3055 Family Planning Waiver New Enrollee Letter
dma-3055R-I Instructions for Completing the Revised Adult Care Home Personal Care Physician Authorization and Care Plan (DMA-3050R)
dma-3057-ia North Carolina Community Alternatives Program for Children Participation Notice
dma-3059-ia Sterilization Consent Form
dma-3063-ia CAP/C – Physician’s Request Form for In-Home Nursing Services
dma-3065 PCS Medical Attestation for Licensed Care Home Residents
dma-3066 PCS for Licensed ACH Residents – Independent Assessment request for New Residents
dma-3072-ia Self-Assessment Tools
dma-3073-ia Individual Risk Assessment
dma-3085-I- Session Law 2013-306 PCS Training Attestation Form DMA-3085
dma-3085-ia Session Law 2013-306 PCS Training Attestation Form May 30, 2018
dma-3087-ia Service Request for Home and Community-Based Services – PHYSICIANS ATTESTATION
dma-3114-I-ia Instructions – Request for Reconsideration of PCS Authorization (DMA-3114)
dma-3114-ia Request for Reconsideration of PCS Authorization
dma-3116-I Instructions – Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form (DMA-3116)
dma-3116-ia Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form
dma-3125 Oral Nutrition Product Request Form
dma-3136-ia Internal Quality Improvement Program Attestation Form
dma-3136-ia-i Internal Quality Improvement Program Attestation Form – Instructions
dma-3137 Personal Care Services (PCS) ICD-10 Transition Form Jun 01, 2018
dma-3137-i Personal Care Services (PCS) ICD-10 Transition Form – Instructions
dma-3142-ia Abortion Statement (DMA-3142-IA)
dma-3155 HIV Case Management – Medical Home Communication Tracker
dma-3156 HIV Case Management – Continuing Education Hours Approval Form
dma-3157 HIV Case Management Provider Recertification Application Checklist
dma-3158 HIV Case Management Provider Recertification Application
dma-3158-I HIV Case Management Provider Recertification Application – Instructions
dma-3159 HIV Case Management Basic Training Request Form
dma-3163-ia NC DMA – Community Alternatives Program for Children (CAP/C) Referral Form
dma-3165-ia Notification of Hospice and Personal Care Services (PCS) Coordination Form
dma-3171-I Verification of School Nursing – Instructions
dma-3171-ia Verification of School Nursing
dma-3172 Private Duty Nursing Employment Attestation Form
dma-3173 Verification of Employment Form
dma-3201-ia Critical Incident Report – Community Alternatives Program for Children (CAP-C)
dma-3212-ia NC Medicaid Hospice Prior Approval Authorization
dma-3350 Prior Approval Form for Lower Extremity Prosthetic Component L5781 or L5782
dma-3351 Prior Approval Form for Lower Extremity Prosthetic Component L5930
dma-3352 Prior Approval Form for Lower Extremity Prosthetic Component L5968
dma-3353 Prior Approval Form for Lower Extremity Prosthetic Component L5980
dma-3354 Prior Approval Form for Lower Extremity Prosthetic Component L5987
dma-3355 Prior Approval Form for Lower Extremity Prosthetic Component L5988
dma-3400 Request for HCPCS Code Addition – Medicaid Home Health Fee Schedule
dma-3504 Notice of Approval of Service Request
dma-3600 Tocolytic Prior Approval Request Form
DMA-3611 Dupixent for Asthma
dma-3701-ia N.C. Health Choice Extended Coverage
dma-3701sp-ia Cobertura Extendida de NC Health Choice
dma-372-124-ach-ia Adult Care Home FL2 Form
dma-5001sp AVISO DEL USO DE NUMEROS DE SEGURO SOCIAL Feb 04, 2022
dma-5004 Buy-In Clerical Action
dma-5008b-ia Long Term Care Budget Supplement B to DMA-5008
dma-5008c Spouse and Dependent Income Allowance Worksheet
dma-5008c-ia Spouse and Dependent Income Allowance Worksheet
dma-5008e ABD Medicaid Parent to Child Deeming Budget Sheet
dma-5008e-ia ABD Medicaid Parent to Child Deeming Budget Sheet
dma-5009 Social History Summary for the Disabled
dma-5009-ia Social History Summary for the Disabled
dma-5010-ia Referral for Inpatient Hospital and Intermediate Care Facility in State Mental Hospital/State Mental Retardation Centers
dma-5011-ia Managed Care Organization (MCO) Health Plan Welcome Letter
dma-5011a CAP Indicator Letter (Memorandum)
dma-5012 Managed Care Organization (MCO) Health Plan Transfer Letter
dma-5020 Notice of Case Status
dma-5020-ia Notice of Case Status
dma-5022-ia Eligibility Information System
dma-5024sp-ia Notificacion de Solicitud de Transporte Jan 26, 2021
dma-5026 Notice of Obligation to Apply for Veteran’s Benefits
dma-5027 Verification of VA Benefits
dma-5031A Verification of Pregnancy
dma-5032 Presumptive Eligibility Determination Form for Pregnancy – Related Care
dma-5032-(H) Presumptive Eligibility Determination by Hospital
dma-5032sp Formulario De Determinación De Elegibilidad Presunta Para Recibir Atención Relacionada Con El Embarazo
dma-5033 Presumptive Eligibility Transmittal Form
dma-5033sp Formulario De Transmisión De Elegibilidad Presunta
dma-5034 Presumptive Eligibility Income Checklist
dma-5034sp Lista de Verification de Ingresos Para Elegibilidad Presunta
dma-5035 Presumptive Eligibility Denial
dma-5035sp Denegacion de Elegibilidad Presunta
dma-5036 Record of Medical Expenses Applied to the Deductible
dma-5037 Medical Provider Verification Form
dma-5039 Right to Rebut Value of Vehicles
dma-5041 Doctor’s Statement of Due Date
dma-5042 Mail-In Application, Additional Information
dma-5042-ia Additional Information Needed for Mail-In Application
dma-5043 Self-Employment Income and Expenses Verification Form
dma-5043-ia Self-Employment Income and Expenses Verification Form
dma-5044 Consent for Release of Information
dma-5045 Certification of Need For Institutional Care for Individual Under Age 21
dma-5050-ia Emergency Certification for Medicaid
dma-5055-ia Third Party Resource Transmittal
dma-5057 Explanation Of The Effect Of Transfer Of Asset (s) On Medical Assistance Eligibility
dma-5057sp Explicación De Los Efectos De La Transferencia De Activos Sobre La Elegibilidad Para Asistencia Médica
dma-5058 Participating Telephone Service Providers
dma-5066 NC Health Choice/Medicaid Mail-In Applications – Log
dma-5066-ia NC Health Choice/Medicaid Mail-In Applications – Log
dma-5069 Special Health Care Needs Questionnaire
dma-5069sp Cuestionario para Necesidades Especiades de Salud
dma-5071i NC Health Choice Designation of Authorized Representative Form
dma-5071sp NC Health Choice: Designación De Representante Autorizo
dma-5072i NC Health Choice First Level Review Request Form
dma-5072sp Explicación Del Proceso De Revisión De Primer Nivel
dma-5073-ia NC Health Choice – External Second Level Review Request Form
dma-5073sp Explanación Del Proceso De Revisión De Segundo Nivel
dma-5086 Request for Access to DHHS Provider Penalty Tracking Database
dma-5093-ia DAILY RECEPTION LOG FOR MEDICAL AND FINANCIAL ASSISTANCE
dma-5094 Notice of Your Right to Apply for Benefits
dma-5094sp Aviso de Su Derecho a Solicitar Beneficios
dma-5096-ia Documentation of Need
dma-5097-ia Request for Information
dma-5097sp Solicitud de información
dma-5098sp-ia Su Solicitud Para Medicaid Esta Pendiente
dma-5100 Notice of Medicaid Redetermination
dma-5100sp Aviso De Redeterminación De Medicaid
dma-5100sp Aviso De Redeterminación De Medicaid
dma-5101 Notice of Approval
dma-5102 SSI Denial
dma-5102sp Negación de SSI
dma-5103D SSI Medicaid Denial Due to Refusal to Provide Health Insurance Information
dma-5103Dsp Denegación De Medicaid Por Medio De La Ssi Debido A La Negativa De Suministrar Información Sobre El Seguro De Salud
dma-5103T SSA Medicaid Termination Due to Refusal to Provide Health Insurance Information
dma-5103Tsp Cancelación De Medicaid Por Medio De La Ssi Debido A La Negativa De Suministrar Información Sobre El Seguro De Salud
dma-5105 Adult Mail-In Application Log
dma-5105-ia Adult Mail-In Application Log
dma-5108 Provider Transportation Record
dma-5109 Model No-Show Policy for Community Transportation Systems
dma-5110-ia Disclosure of Annuities
dma-5111-ia Verification of Annuities Properties
dma-5112-ia Informational Notice Regarding Annuities and Medicaid Eligibility
dma-5113-ia Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets)
dma-5114-ia Request for Documentation for Undue Hardship Claim
dma-5115-ia Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value)
dma-5122 Community Spouse Resource Protection Worksheet
dma-5124 Medicaid Transportation Provider Documentation
dma-5124a Medicaid Transportation Provider Documentation Addendum
dma-5127 Notice of Reactivating The Health Check/Health Choice Program
dma-5127sp Notice of Reactivating The Health Check/Health Choice Program
dma-5128 Health Choice Enrollment & Waiting List Notification
dma-5128sp Registro de Health Choice & Lista de Espera Notification
dma-5131 FAX Request Form – From County DSS to EOIR
dma-5132 FAX Request Form – From County DSS to USCIS
dma-5133 Emergency Medical Services Request for Information
dma-5134 Emergency Medical Services Request for Missing Information
dma-5135 Dates of Emergency Services Requested for an Alien
dma-5141 Medicare/Medicare Part B Enrollment Advisory Letter (Automated)
dma-5146 Health Coverage for Workers with Disabilities Premium Notice
dma-5147 HCWD Denial for Non-Payment of Premium
dma-5148 HCWD Termination for Non-Payment of Premiums
dma-5149 HCWD Enrollment Fee Notice
dma-5151 Health Coverage For Workers With Disabilities (HCWD) Medical Information Release Authorization
dma-5154 County Transfer Letter
dma-5154 sp County Transfer Letter
dma-5154-ia County Transfer Letter
DMA-5154sp-ia CARTA DE TRASLADO DE CONDADO
dma-5155 Verification of Cash Value of Life Insurance
dma-5156 Statement of Outstanding Checks
dma-5157 Notice of Total Countable Resources; Right To Rebut Value
DMA-5157 SP Notice of Total Countable Resources; Right to Rebute Value
dma-5158 INCOME PRODUCING PROPERTY GUIDE
dma-5159 Statement of Intent to Return Home
dma-5160 Statement Of Spouse Or Dependent Relative In The Home
dma-5161 Transfer Of Asset Below Current Market Value Important Notice
dma-5167 County Analysis – Non-Compliance with Processing Thresholds or Thresholds for Denials, Withdrawals, Inquiries
dma-5168 Actions Taken On Improper Denials, Withdrawals, Or Inquiries Identified In Monitoring
dma-5169 Report Card Analysis
dma-5171 Approval Notice For Retroactive Medicaid Benefits
dma-5172 Erroneous Authorization Dates of Medicaid Eligibility
dma-5176 U.S. Citizenship Documentation Birth Certificate Request
dma-5178 U.S. Citizenship Documentation Desk Reference
dma-5180 SSI Check Terminated: Information Needed to Determine Medicaid Eligibility
dma-5181 Calculating Penalty Period – Transfers 11/1/07 or Later
dma-5182 Notice Of Cooperation In Establishing Paternity And Or Medical Support
dma-5183 Presumptive Eligibility Log
dma-5199-ia Medicaid Renewal Request for Information Notice
dma-5199sp-ia Aviso de pedido de información para la renovación de Medicaid
dma-5202A-ia Health Coverage from Jobs – Appendix A
dma-5202Asp-ia Apéndice A – Coberta de salud de empleos
dma-5202B-ia American Indian or Alaska Native Family Member (AI/AN) – Appendix B
dma-5202Bsp-ia Apéndice B – Miembro de la familia amerindio o nativo de Alaska (AI/AN)
dma-5202Csp-ia Apéndice C – Designación de representante autorizado
DMA-5202D-ia Income/Resources – Appendix D
DMA-5202DSp-ia Apéndice D – Ingresos/Recursos
DMA-7010 Reports of Referrals to Law Enforcement
DMA-7057 Referral For Investigation
DMA-7098-ia Request and Authorization to Disclose Health Information
DMA-9001 Carolina ACCESS Complaint Form Instructions
DMA-9002-ia CCNC/CA – Medical Exemption Request
DMA-9006 Carolina ACCESS Enrollment Form for Recipients of Medicaid and Health Choice
DMA-9006-ia Carolina ACCESS Enrollment Form
DMA-9007 Mail-In Application/Reenrollment Form
DMA-9008-SSI Recipient without Medicare
DMA-9009 SSI Recipient with Medicare
DMA-9010 County Transfer
DMA-9010sp ia Transferencia de condado
DMA-9011 Change in Primary Doctor Practice
DMA-9012 Primary Care Provider Disenrolls Recipient
DMA-9013 Recipient with a Temporary Exempt
DMA-9016 CCNC/CA The Benefits of Being A Member-Medicaid
DMA-9016 Russian CCNC/CA: ПРЕИМУЩЕСТВА УЧАСТИЯ В ПРОГРАММЕ MEDICAID
DMA-9016 Vietnamese CCNC/CA: LỢI ÍCH KHI LÀ THÀNH VIÊN MEDICAID
DMA-9016sp CCNC/CA: Las Ventajas de Ser Mirembro-Medicaid
DMA-9017 CCNC/CA: The Benefits of Being a Member-NCHC
DMA-9017sp CCNC/CA, Los Beneficios de Ser Miembro-NCHC
DMA-9050-ia Nursing Home Notice of Transfer/Discharge
DMA-9051-ia Nursing Home Hearing Request Form
DMA-9052-ia Adult Care Home Notice of Transfer/Discharge
DMA-9053-ia Adult Care Home Hearing Request Form
DSS-8110 CHANGE/TERMINATION ADEQUATE
DSS-8110 CHANGE/TERMINATION TIMELY
DSS-8110 CONTINUING
DSS-8110 Transitional
DSS-8110sp CHANGE/TERMINATION ADEQUATE
DSS-8110sp CHANGE/TERMINATION TIMELY
DSS-8110sp CONTINUING
DSS-8110sp Transitional

DHB Forms