| DHB-1061 Checklist for Child Medical Evaluation (CME) Reporting | Form | pdf | 291 KB | |
| DHB-2039 PHP Notification of Nursing Facility Level of Care | Form | pdf | 239 KB | |
| DHB-2040 Tribal and Indian Health Services | Form | pdf | 155 KB | |
| DHB-2040B Tribal and Indian Health Services | Form | pdf | 189 KB | |
| DHB-2043 Third Party Recovery Accident Information Form | Form | pdf | 797 KB | |
| DHB-2044ia Medicaid Credit Balance Report | Form | pdf | 189 KB | |
| DHB-2045 Instructions for Completing Medicaid Credit Balance Report | Form | pdf | 141 KB | |
| DHB-2050 Voluntary Request to Terminate Medicaid | Form | pdf | 114 KB | |
| DHB-2055 Reimbursement for Medical Transportation | Form | xls | 34 KB | |
| DHB-2056 Purchased Medical Transportation Costs | Form | xls | 83 KB | |
| DHB-2190 Internal Inspection Report | Form | pdf | 483 KB | |
| DHB-2191 Designation of Control Officer for FRR/Beer Reports | Form | pdf | 217 KB | |
| DHB-2192 SSA Training Form – County Staff and County Contract Staff | Form | pdf | 95 KB | |
| DHB-2193 Memorandum of CAP Waiver Enrollment | Form | pdf | 253 KB | |
| DHB-2194 IRC Rules Handout | Form | pdf | 139 KB | |
| DHB-2195 Documentation of Annual Security Training Confidentiality Form – County Staff | Form | pdf | 102 KB | |
| DHB-2196 Documentation of Annual Security Training – Shred Contractor Training | Form | pdf | 103 KB | |
| DHB-2197 FTI Record Keeping Log | Form | xls | 30 KB | |
| DHB-2198 Log for Destruction of the FRR/BEER Reports | Form | pdf | 80 KB | |
| DHB-2199 Documentation of the Visitation Logs | Form | pdf | 45 KB | |
| DHB-2200 Access Control Log | Form | pdf | 45 KB | |
| DHB-2201 Confidentiality of Safeguard Data | Form | pdf | 140 KB | |
| DHB-2202 Beneficiary Notice | Form | pdf | 79 KB | |
| DHB-3051-ia Form and Instructions – Request for Independent Assessment for Personal Care Services – Attestation of Medical Need | Form | pdf | 494 KB | |
| DHB-4037 Disability Determination Transmittal | Form | pdf | 165 KB | |
| DHB-5001N Notice on the Use of Social Security Numbers | Form | pdf | 107 KB | |
| DHB-5001N_sp AVISO SOBRE EL USO DE LOS N√öMEROS DE SEGURO SOCIAL | Form | pdf | 186 KB | |
| DHB-5002 Important Notice About Your Medicaid or Special Assistance Approval | Form | pdf | 768 KB | |
| DHB-5002sp-ia Lea Este Importante Aviso Sobre Medicail o la Asistencia Especial Aviso de Aprobacion | Form | pdf | 296 KB | |
| DHB-5003 Medicaid Approval Notice | Form | pdf | 349 KB | |
| DHB-5003sp-ia LEA ESTE IMPORTANTE AVISO SOBRE MEDICAID AVISO DE APROBACION | Form | pdf | 265 KB | |
| DHB-5004-ia Buy-In Clerical Action | Form | pdf | 201 KB | |
| DHB-5008a Adult Budget Sheet | Form | pdf | 186 KB | |
| DHB-5008B Supplement B | Form | pdf | 118 KB | |
| DHB-5008c-ia Spouse and Dependent Income Allowance Worksheet | Form | pdf | 62 KB | |
| DHB-5008e ABD Medicaid Parent To Child Deeming Budgeting Sheet | Form | pdf | 221 KB | |
| DHB-5009 Social History Summary For The Disabled | Form | pdf | 146 KB | |
| DHB-5016-ia Notification of Eligibility for Medicaid/Amount and Effective Date of Patient’s Liability | Form | pdf | 140 KB | |
| DHB-5024 Transportation Assessment Notification | Form | pdf | 139 KB | |
| DHB-5024sp Aviso de Evaluación de Transporte | Form | pdf | 103 KB | |
| DHB-5026 Notice Of Obligation To Apply For Veteran’s Benefits | Form | pdf | 105 KB | |
| DHB-5027 Veteran’s Benefits Verification Letter | Form | pdf | 141 KB | |
| DHB-5028-ia Authorization to Disclose Information | Form | pdf | 259 KB | |
| DHB-5036 Record Of Medical Expenses Applied To The Deductible | Form | pdf | 218 KB | |
| DHB-5043 Verification Form For Self-Employment Income and Expenses | Form | pdf | 143 KB | |
| DHB-5043-ia Verification Form For Self-Employment Income and Expenses | Form | pdf | 79 KB | |
| DHB-5046 Notice of Rights/Responsibilities – Medical Transportation Assistance (English & Spanish) | Form | pdf | 141 KB | |
| DHB-5047 Medicaid Transportation Assessment | Form | pdf | 323 KB | |
| DHB-5048 Medicaid Transportation Exception Verification | Form | pdf | 326 KB | |
| DHB-5051 Estate Subject To Medicaid Recovery: Individuals Under Age 55 | Form | pdf | 238 KB | |
| DHB-5051sp Notice of Medicaid Recovery – People Under 55 (Spanish) | Form | pdf | 238 KB | |
| DHB-5052 NOTICE: YOUR ESTATE IS SUBJECT TO MEDICAID RECOVERY | Form | pdf | 245 KB | |
| DHB-5052 sp AVISO IMPORTANTE SU PATRIMONIO ESTÁ SUJETO A RECUPERACIÓN DE MEDICAID | Form | pdf | 251 KB | |
| DHB-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice | Form | pdf | 150 KB | |
| DHB-5052SA-sp Notificación al Beneficiario de la Asistencia Especial Del Estado/Condado Sobre la Recuperación de los Gasto Médicos Pagados por Medicaid | Form | pdf | 207 KB | |
| DHB-5053 Estate Recovery – Permanently Institutionalized | Form | pdf | 151 KB | |
| DHB-5053sp SU PATRIMONIO ESTÁ SUJETO A RECUPERACIÓN DE MEDICAID | Form | pdf | 146 KB | |
| DHB-5054 Estate Recovery – Claim Notice | Form | pdf | 165 KB | |
| DHB-5054sp – Estate Recovery – Claim Notice (Spanish) | Form | pdf | 139 KB | |
| DHB-5056 Estate Recovery Information Form | Form | pdf | 117 KB | |
| DHB-5076 Pregnancy Management Program | Form | pdf | 76 KB | |
| DHB-5076 Pregnancy Management Program -Spanish Version | Form | pdf | 82 KB | |
| DHB-5078 Medicaid Transportation Monitoring Report | Form | pdf | 123 KB | |
| DHB-5079 Breast and Cervical Cancer Medicaid Application | Form | pdf | 393 KB | |
| dhb-5079sp Solicitud de Medicaid para c√°ncer de seno y de cuello uterino | Form | pdf | 404 KB | |
| dhb-5081-ia Breast and Cervical Cancer Verification: Screening, Diagnosis and Treatment | Form | pdf | 199 KB | |
| dhb-5081r-ia Breast and Cervical Cancer Recertification: Screening, Diagnosis and Treatment | Form | pdf | 150 KB | |
| dhb-5081r-sp-ia Para Seguir Recibiendo Cobertura De Medicaid Para El Cancer De Seno Y El Cancer Del Cuello Uterino | Form | pdf | 146 KB | |
| dhb-5081sp-ia Verificacion De Evaluacion, Diagnostico Y Tratamiento | Form | pdf | 147 KB | |
| dhb-5082 Transitional Benefit Report | Form | pdf | 185 KB | |
| dhb-5083 Notice of Transitional Benefits | Form | pdf | 199 KB | |
| dhb-5083sp Aviso De Beneficios Transitorios | Form | pdf | 206 KB | |
| dhb-5084 Transitional Benefits Good Cause | Form | pdf | 149 KB | |
| dhb-5084sp Motivos Justificados Para No Haber Entregado A Tiempo Su Informe De Beneficios Transitorios | Form | pdf | 136 KB | |
| dhb-5087-ia Check List For Breast and Cervical Cancer Medicaid | Form | pdf | 192 KB | |
| dhb-5087-sp Check List For Breast and Cervical Cancer Medicaid | Form | pdf | 91 KB | |
| DHB-5097 Request for Information | Form | pdf | 221 KB | |
| DHB-5097sp-ia Solicitud de información | Form | pdf | 186 KB | |
| DHB-5098-ia Your Application for Medicaid is Pending | Form | pdf | 21 KB | |
| DHB-5104 Notice of Incomplete Application | Form | pdf | 114 KB | |
| DHB-5104sp Notificación de Solicitud Incompleta | Form | pdf | 135 KB | |
| dhb-5106 Medicaid Pace Program Referral | Form | pdf | 280 KB | |
| DHB-5111 Annuity Verification Form | Form | pdf | 115 KB | |
| DHB-5113, Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets) | Form | pdf | 133 KB | |
| DHB-5115 Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value) | Form | pdf | 163 KB | |
| DHB-5118A-ia Medicaid Transportation Verification of Receipt of Covered Service – A | Form | pdf | 36 KB | |
| DHB-5118B-ia Medicaid Transportation Verification of Receipt of Covered Service- B | Form | pdf | 41 KB | |
| DHB-5119 Denial of Transportation Request(s) | Form | pdf | 130 KB | |
| DHB-5119sp Negación de Solicitudes de Transporte | Form | pdf | 129 KB | |
| dhb-5121 Determining Potential Medicaid Eligibility | Form | pdf | 150 KB | |
| DHB-5122 Community Spouse Resource Protection Worksheet | Form | pdf | 124 KB | |
| DHB-5125 Medicaid Transportation No-Show Notice | Form | pdf | 80 KB | |
| DHB-5125a Medicaid Transportation No-Show Final Notice | Form | pdf | 81 KB | |
| DHB-5125Asp Aviso final: Usted no usó el transporte de Medicaid | Form | pdf | 173 KB | |
| DHB-5125B Medicaid Transportation Suspension Notice | Form | pdf | 62 KB | |
| DHB-5125Bsp Aviso de Suspensión de Transporte de Medicaid | Form | pdf | 122 KB | |
| DHB-5125sp Aviso: Usted no usó el transporte de Medicaid | Form | pdf | 169 KB | |
| DHB-5152 North Carolina Residency Declaration | Form | pdf | 129 KB | |
| DHB-5152sp Declaración de residencia en Carolina del Norte | Form | pdf | 110 KB | |
| DHB-5161 Transfer of Asset Below Current Market Value | Form | pdf | 125 KB | |
| DHB-5164 Change to PML Request Memo | Form | pdf | 207 KB | |
| DHB-5165 PACE Referral Request For A Medicaid Hearing | Form | pdf | 159 KB | |
| DHB-5166 PACE Application Report | Form | pdf | 180 KB | |
| DHB-5170 Request for Claims Override | Form | pdf | 242 KB | |
| dhb-5179 MAABD Eligibility Overview Chart | Form | pdf | 277 KB | |
| DHB-5181 5181 Calculating Penalty Period – Transfers 11/1/07 or Later | Form | pdf | 110 KB | |
| DHB-5200-ia Application for Health Coverage & Help Paying Costs | Form | pdf | 916 KB | |
| DHB-5200sp Solicitud Para Cobertura de Salud y Ayuda Para Pagar los Costos | Form | pdf | 2 MB | |
| DHB-5201-ia Application for Health Coverage & Help Paying Costs (Short Form) | Form | pdf | 568 KB | |
| DHB-5202C-ia Designation of Authorized Representative – Appendix C | Form | pdf | 155 KB | |
| DHB-5202E-ia Medical Bills – Appendix E | Form | pdf | 215 KB | |
| DHB-5202Esp-ia Apéndice E – Facturas médicas | Form | pdf | 119 KB | |
| DHB-7058 Investigative Summary | Form | pdf | 1 MB | |
| dhb-7059 Notice Of Change In Overpayment For Medical Assistance | Form | pdf | 94 KB | |
| dhb-7060 Voluntarty Repayment Agreement | Form | pdf | 853 KB | |
| dhb-7061 Voluntary Wage Withholding Agreement | Form | pdf | 173 KB | |
| dhb-7063 Medicaid/NC Health Choice Recipient Profile Request Sheet Apr 21, 2021 | Form | pdf | 298 KB | |
| DHB-7078A Application 2nd Party Review Worksheet | Form | pdf | 528 KB | |
| DHB-7078R Recertification 2nd Party Review Worksheet | Form | pdf | 515 KB | |
| dhb-7097-ia Recipient Request and Authorization to Disclose Health Information | Form | pdf | 175 KB | |
| dhb-7098-I DMA-7098 – Additional Information and Instructions Feb 23, 2021 | Form | pdf | 146 KB | |
| dhb-8010 Notice of Overpayment For Medical Assistance | Form | pdf | 217 KB | |
| dhb-8010sp Notice of Overpayment For Medical Assistance (Spanish Version) | Form | pdf | 131 KB | |
| DHB-8020-ia Medicaid Eligibility Corrections Form | Form | pdf | 323 KB | |
| DMA 9006sp Formulario de inscripción en CCNC/CA | Form | pdf | 133 KB | |
| dma-0100 Physician’s Signature for Authorization of Level of Care | Form | pdf | 89 KB | |
| dma-1049 Cover Letter for LIS Application for Medicaid | Form | pdf | 12 KB | |
| dma-1050 Notice of Application for Extra Help with Medicare Prescription Drug Costs | Form | pdf | 13 KB | |
| dma-1051 LIS Verification Checklist | Form | pdf | 65 KB | |
| dma-1051-ia LIS Verification Checklist | Form | pdf | 170 KB | |
| dma-1052 Notice of Approval for Extra Help with Medicaire Prescription Drug Costs | Form | pdf | 28 KB | |
| dma-1052-ia Notice of Approval for Extra Help with Medicare Prescription Drug Costs | Form | pdf | 76 KB | |
| dma-1053 Medicare Prescription Drug Subsidy Assistance | Form | pdf | 45 KB | |
| dma-1053-ia Medicare Prescription Drug Subsidy Assistance | Form | pdf | 45 KB | |
| dma-1054 Report of Approval/Denial of LIS Application | Form | pdf | 32 KB | |
| dma-2000a County DSS Request for DMA Forms | Form | pdf | 100 KB | |
| dma-2000h Health Agencies Request for DMA Forms | Form | pdf | 158 KB | |
| dma-2000x Order Form for NC Medicaid Consumer Guides | Form | pdf | 82 KB | |
| dma-2041-ia Third Party Recovery Insurance Information | Form | pdf | 106 KB | |
| dma-2046 Third Party Liability Medicaid and NC Health Choice Billing Guide | Form | pdf | 484 KB | |
| dma-2053-ia Insurance Company Code Request Form | Form | pdf | 89 KB | |
| dma-2057 Health Insurance Information Referral Form | Form | pdf | 5 KB | |
| dma-2069 Health Insurance Premium Payment Program Application | Form | pdf | 140 KB | |
| dma-2073 Medicaid Payment Information Request | Form | pdf | 28 KB | |
| dma-2073-I Instructions for Medicaid Payment Information Request | Form | pdf | 17 KB | |
| dma-2188 Notice of Privacy Practices | Form | pdf | 137 KB | |
| dma-2188sp Aviso De Pr√°cticas De Privacidad | Form | pdf | 46 KB | |
| dma-2190 Report of Internal Inspection FRR/BEER | Form | pdf | 717 KB | |
| dma-2191 Designation of Control Officer for FRR/BEER | Form | pdf | 656 KB | |
| dma-2192 Documentation of SSA Security Training | Form | pdf | 680 KB | |
| dma-3002 Program Care Coordinator Pregnancy Outcome Report | Form | pdf | 112 KB | |
| dma-3004 Maternity Care Coordination Letter of Agreement | Form | pdf | 31 KB | |
| dma-3005 Care Coordinator Appointment Record | Form | pdf | 45 KB | |
| dma-3006 Care Coordination Record | Form | pdf | 165 KB | |
| dma-3007-ia Family Care Coordination Plan | Form | pdf | 207 KB | |
| dma-3016 Care Coordination Narrative Sheet | Form | pdf | 44 KB | |
| dma-3019 Individual Authorization Form | Form | pdf | 47 KB | |
| dma-3047 Hysterectomy Statement Form | Form | pdf | 139 KB | |
| dma-3050R Adult Care Home Personal Care Physician | Form | pdf | 407 KB | |
| dma-3055 Family Planning Waiver New Enrollee Letter | Form | pdf | 35 KB | |
| dma-3055R-I Instructions for Completing the Revised Adult Care Home Personal Care Physician Authorization and Care Plan (DMA-3050R) | Form | pdf | 38 KB | |
| dma-3057-ia North Carolina Community Alternatives Program for Children Participation Notice | Form | pdf | 97 KB | |
| dma-3059-ia Sterilization Consent Form | Form | pdf | 242 KB | |
| dma-3063-ia CAP/C – Physician’s Request Form for In-Home Nursing Services | Form | pdf | 36 KB | |
| dma-3065 PCS Medical Attestation for Licensed Care Home Residents | Form | pdf | 248 KB | |
| dma-3066 PCS for Licensed ACH Residents – Independent Assessment request for New Residents | Form | pdf | 231 KB | |
| dma-3072-ia Self-Assessment Tools | Form | pdf | 273 KB | |
| dma-3073-ia Individual Risk Assessment | Form | pdf | 41 KB | |
| dma-3085-I- Session Law 2013-306 PCS Training Attestation Form DMA-3085 | Form | pdf | 33 KB | |
| dma-3085-ia Session Law 2013-306 PCS Training Attestation Form May 30, 2018 | Form | | | |
| dma-3087-ia Service Request for Home and Community-Based Services – PHYSICIANS ATTESTATION | Form | pdf | 441 KB | |
| dma-3114-I-ia Instructions – Request for Reconsideration of PCS Authorization (DMA-3114) | Form | pdf | 274 KB | |
| dma-3114-ia Request for Reconsideration of PCS Authorization | Form | pdf | 201 KB | |
| dma-3116-I Instructions – Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form (DMA-3116) | Form | pdf | 226 KB | |
| dma-3116-ia Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form | Form | pdf | 526 KB | |
| dma-3125 Oral Nutrition Product Request Form | Form | pdf | 30 KB | |
| dma-3136-ia Internal Quality Improvement Program Attestation Form | Form | pdf | 213 KB | |
| dma-3136-ia-i Internal Quality Improvement Program Attestation Form – Instructions | Form | pdf | 32 KB | |
| dma-3137 Personal Care Services (PCS) ICD-10 Transition Form Jun 01, 2018 | Form | | | |
| dma-3137-i Personal Care Services (PCS) ICD-10 Transition Form – Instructions | Form | pdf | 298 KB | |
| dma-3142-ia Abortion Statement (DMA-3142-IA) | Form | pdf | 127 KB | |
| dma-3155 HIV Case Management – Medical Home Communication Tracker | Form | pdf | 543 KB | |
| dma-3156 HIV Case Management – Continuing Education Hours Approval Form | Form | pdf | 684 KB | |
| dma-3157 HIV Case Management Provider Recertification Application Checklist | Form | pdf | 213 KB | |
| dma-3158 HIV Case Management Provider Recertification Application | Form | pdf | 128 KB | |
| dma-3158-I HIV Case Management Provider Recertification Application – Instructions | Form | pdf | 189 KB | |
| dma-3159 HIV Case Management Basic Training Request Form | Form | pdf | 173 KB | |
| dma-3163-ia NC DMA – Community Alternatives Program for Children (CAP/C) Referral Form | Form | pdf | 523 KB | |
| dma-3165-ia Notification of Hospice and Personal Care Services (PCS) Coordination Form | Form | pdf | 414 KB | |
| dma-3171-I Verification of School Nursing – Instructions | Form | pdf | 346 KB | |
| dma-3171-ia Verification of School Nursing | Form | pdf | 442 KB | |
| dma-3172 Private Duty Nursing Employment Attestation Form | Form | pdf | 250 KB | |
| dma-3173 Verification of Employment Form | Form | pdf | 153 KB | |
| dma-3201-ia Critical Incident Report – Community Alternatives Program for Children (CAP-C) | Form | pdf | 298 KB | |
| dma-3212-ia NC Medicaid Hospice Prior Approval Authorization | Form | pdf | 110 KB | |
| dma-3350 Prior Approval Form for Lower Extremity Prosthetic Component L5781 or L5782 | Form | pdf | 25 KB | |
| dma-3351 Prior Approval Form for Lower Extremity Prosthetic Component L5930 | Form | pdf | 19 KB | |
| dma-3352 Prior Approval Form for Lower Extremity Prosthetic Component L5968 | Form | pdf | 20 KB | |
| dma-3353 Prior Approval Form for Lower Extremity Prosthetic Component L5980 | Form | pdf | 19 KB | |
| dma-3354 Prior Approval Form for Lower Extremity Prosthetic Component L5987 | Form | pdf | 19 KB | |
| dma-3355 Prior Approval Form for Lower Extremity Prosthetic Component L5988 | Form | pdf | 19 KB | |
| dma-3400 Request for HCPCS Code Addition – Medicaid Home Health Fee Schedule | Form | pdf | 601 KB | |
| dma-3504 Notice of Approval of Service Request | Form | pdf | 243 KB | |
| dma-3600 Tocolytic Prior Approval Request Form | Form | pdf | 34 KB | |
| DMA-3611 Dupixent for Asthma | Form | pdf | 114 KB | |
| dma-3701-ia N.C. Health Choice Extended Coverage | Form | pdf | 92 KB | |
| dma-3701sp-ia Cobertura Extendida de NC Health Choice | Form | pdf | 64 KB | |
| dma-372-124-ach-ia Adult Care Home FL2 Form | Form | pdf | 213 KB | |
| dma-5001sp AVISO DEL USO DE NUMEROS DE SEGURO SOCIAL Feb 04, 2022 | Form | | | |
| dma-5004 Buy-In Clerical Action | Form | pdf | 204 KB | |
| DMA-5008a North Carolina division of Medical Assistance Adult Budget Sheet | Form | pdf | 189 KB | |
| dma-5008b-ia Long Term Care Budget Supplement B to DMA-5008 | Form | pdf | 130 KB | |
| dma-5008c Spouse and Dependent Income Allowance Worksheet | Form | pdf | 51 KB | |
| dma-5008c-ia Spouse and Dependent Income Allowance Worksheet | Form | pdf | 63 KB | |
| dma-5008e ABD Medicaid Parent to Child Deeming Budget Sheet | Form | pdf | 46 KB | |
| dma-5008e-ia ABD Medicaid Parent to Child Deeming Budget Sheet | Form | pdf | 85 KB | |
| dma-5009 Social History Summary for the Disabled | Form | pdf | 25 KB | |
| dma-5009-ia Social History Summary for the Disabled | Form | pdf | 51 KB | |
| dma-5010-ia Referral for Inpatient Hospital and Intermediate Care Facility in State Mental Hospital/State Mental Retardation Centers | Form | pdf | 474 KB | |
| dma-5011-ia Managed Care Organization (MCO) Health Plan Welcome Letter | Form | pdf | 104 KB | |
| dma-5011a CAP Indicator Letter (Memorandum) | Form | pdf | 11 KB | |
| dma-5012 Managed Care Organization (MCO) Health Plan Transfer Letter | Form | pdf | 12 KB | |
| dma-5020 Notice of Case Status | Form | pdf | 77 KB | |
| dma-5020-ia Notice of Case Status | Form | pdf | 58 KB | |
| dma-5022-ia Eligibility Information System | Form | pdf | 160 KB | |
| dma-5024sp-ia Notificacion de Solicitud de Transporte Jan 26, 2021 | Form | | | |
| dma-5026 Notice of Obligation to Apply for Veteran’s Benefits | Form | pdf | 23 KB | |
| dma-5027 Verification of VA Benefits | Form | pdf | 23 KB | |
| dma-5031A Verification of Pregnancy | Form | pdf | 27 KB | |
| dma-5032 Presumptive Eligibility Determination Form for Pregnancy – Related Care | Form | pdf | 129 KB | |
| dma-5032-(H) Presumptive Eligibility Determination by Hospital | Form | pdf | 522 KB | |
| dma-5032sp Formulario De Determinación De Elegibilidad Presunta Para Recibir Atención Relacionada Con El Embarazo | Form | pdf | 43 KB | |
| dma-5033 Presumptive Eligibility Transmittal Form | Form | pdf | 44 KB | |
| dma-5033sp Formulario De Transmisión De Elegibilidad Presunta | Form | pdf | 26 KB | |
| dma-5034 Presumptive Eligibility Income Checklist | Form | pdf | 149 KB | |
| dma-5034sp Lista de Verification de Ingresos Para Elegibilidad Presunta | Form | pdf | 79 KB | |
| dma-5035 Presumptive Eligibility Denial | Form | pdf | 78 KB | |
| dma-5035sp Denegacion de Elegibilidad Presunta | Form | pdf | 17 KB | |
| dma-5036 Record of Medical Expenses Applied to the Deductible | Form | pdf | 200 KB | |
| dma-5037 Medical Provider Verification Form | Form | pdf | 12 KB | |
| dma-5039 Right to Rebut Value of Vehicles | Form | pdf | 11 KB | |
| dma-5041 Doctor’s Statement of Due Date | Form | pdf | 16 KB | |
| dma-5042 Mail-In Application, Additional Information | Form | pdf | 11 KB | |
| dma-5042-ia Additional Information Needed for Mail-In Application | Form | pdf | 29 KB | |
| dma-5043 Self-Employment Income and Expenses Verification Form | Form | pdf | 20 KB | |
| dma-5043-ia Self-Employment Income and Expenses Verification Form | Form | pdf | 81 KB | |
| dma-5044 Consent for Release of Information | Form | pdf | 22 KB | |
| dma-5045 Certification of Need For Institutional Care for Individual Under Age 21 | Form | pdf | 18 KB | |
| dma-5049-ia Referral to Local Social Security Office | Form | pdf | 209 KB | |
| dma-5050-ia Emergency Certification for Medicaid | Form | pdf | 73 KB | |
| dma-5055-ia Third Party Resource Transmittal | Form | pdf | 16 KB | |
| dma-5057 Explanation Of The Effect Of Transfer Of Asset (s) On Medical Assistance Eligibility | Form | pdf | 30 KB | |
| dma-5057sp Explicación De Los Efectos De La Transferencia De Activos Sobre La Elegibilidad Para Asistencia Médica | Form | pdf | 32 KB | |
| dma-5058 Participating Telephone Service Providers | Form | pdf | 19 KB | |
| dma-5066 NC Health Choice/Medicaid Mail-In Applications – Log | Form | pdf | 40 KB | |
| dma-5066-ia NC Health Choice/Medicaid Mail-In Applications – Log | Form | pdf | 32 KB | |
| dma-5069 Special Health Care Needs Questionnaire | Form | pdf | 68 KB | |
| dma-5069sp Cuestionario para Necesidades Especiades de Salud | Form | pdf | 99 KB | |
| dma-5071i NC Health Choice Designation of Authorized Representative Form | Form | pdf | 62 KB | |
| dma-5071sp NC Health Choice: Designación De Representante Autorizo | Form | pdf | 86 KB | |
| dma-5072i NC Health Choice First Level Review Request Form | Form | pdf | 174 KB | |
| dma-5072sp Explicación Del Proceso De Revisión De Primer Nivel | Form | pdf | 62 KB | |
| dma-5073-ia NC Health Choice – External Second Level Review Request Form | Form | pdf | 253 KB | |
| dma-5073sp Explanación Del Proceso De Revisión De Segundo Nivel | Form | pdf | 270 KB | |
| dma-5076 Pregnancy Medical Home Handout | Form | pdf | 26 KB | |
| dma-5076sp Folleto de Pregnancy Medical Home | Form | pdf | 22 KB | |
| dma-5086 Request for Access to DHHS Provider Penalty Tracking Database | Form | pdf | 70 KB | |
| dma-5093-ia DAILY RECEPTION LOG FOR MEDICAL AND FINANCIAL ASSISTANCE | Form | pdf | 60 KB | |
| dma-5094 Notice of Your Right to Apply for Benefits | Form | pdf | 36 KB | |
| dma-5094sp Aviso de Su Derecho a Solicitar Beneficios | Form | pdf | 80 KB | |
| dma-5095 Medicaid/Work First Notice of Inquiry | Form | pdf | 102 KB | |
| dma-5095-ia Medicaid/Work First Notice of Inquiry | Form | pdf | 101 KB | |
| dma-5095sp-ia Aviso De Indagacion Sobre Medicaid/Work First | Form | pdf | 72 KB | |
| dma-5096-ia Documentation of Need | Form | pdf | 174 KB | |
| dma-5097-ia Request for Information | Form | pdf | 51 KB | |
| dma-5097sp Solicitud de información | Form | pdf | 41 KB | |
| dma-5098sp-ia Su Solicitud Para Medicaid Esta Pendiente | Form | pdf | 85 KB | |
| dma-5100 Notice of Medicaid Redetermination | Form | pdf | 20 KB | |
| dma-5100sp Aviso De Redeterminación De Medicaid | Form | pdf | 20 KB | |
| dma-5100sp Aviso De Redeterminación De Medicaid | Form | pdf | 29 KB | |
| dma-5101 Notice of Approval | Form | pdf | 28 KB | |
| dma-5102 SSI Denial | Form | pdf | 20 KB | |
| dma-5102sp Negación de SSI | Form | pdf | 20 KB | |
| dma-5103D SSI Medicaid Denial Due to Refusal to Provide Health Insurance Information | Form | pdf | 20 KB | |
| dma-5103Dsp Denegación De Medicaid Por Medio De La Ssi Debido A La Negativa De Suministrar Información Sobre El Seguro De Salud | Form | pdf | 20 KB | |
| dma-5103T SSA Medicaid Termination Due to Refusal to Provide Health Insurance Information | Form | pdf | 20 KB | |
| dma-5103Tsp Cancelación De Medicaid Por Medio De La Ssi Debido A La Negativa De Suministrar Información Sobre El Seguro De Salud | Form | pdf | 20 KB | |
| dma-5105 Adult Mail-In Application Log | Form | pdf | 17 KB | |
| dma-5105-ia Adult Mail-In Application Log | Form | pdf | 32 KB | |
| dma-5108 Provider Transportation Record | Form | pdf | 80 KB | |
| dma-5109 Model No-Show Policy for Community Transportation Systems | Form | pdf | 116 KB | |
| dma-5110-ia Disclosure of Annuities | Form | pdf | 26 KB | |
| dma-5111-ia Verification of Annuities Properties | Form | pdf | 82 KB | |
| dma-5112-ia Informational Notice Regarding Annuities and Medicaid Eligibility | Form | pdf | 26 KB | |
| dma-5113-ia Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets) | Form | pdf | 31 KB | |
| dma-5114-ia Request for Documentation for Undue Hardship Claim | Form | pdf | 29 KB | |
| dma-5115-ia Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value) | Form | pdf | 28 KB | |
| dma-5122 Community Spouse Resource Protection Worksheet | Form | pdf | 142 KB | |
| dma-5124 Medicaid Transportation Provider Documentation | Form | pdf | 31 KB | |
| dma-5124a Medicaid Transportation Provider Documentation Addendum | Form | pdf | 84 KB | |
| dma-5127 Notice of Reactivating The Health Check/Health Choice Program | Form | pdf | 55 KB | |
| dma-5127sp Notice of Reactivating The Health Check/Health Choice Program | Form | pdf | 54 KB | |
| dma-5128 Health Choice Enrollment & Waiting List Notification | Form | pdf | 25 KB | |
| dma-5128sp Registro de Health Choice & Lista de Espera Notification | Form | pdf | 44 KB | |
| dma-5131 FAX Request Form – From County DSS to EOIR | Form | pdf | 21 KB | |
| dma-5132 FAX Request Form – From County DSS to USCIS | Form | pdf | 24 KB | |
| dma-5133 Emergency Medical Services Request for Information | Form | pdf | 13 KB | |
| dma-5134 Emergency Medical Services Request for Missing Information | Form | pdf | 20 KB | |
| dma-5135 Dates of Emergency Services Requested for an Alien | Form | pdf | 39 KB | |
| dma-5141 Medicare/Medicare Part B Enrollment Advisory Letter (Automated) | Form | pdf | 27 KB | |
| dma-5146 Health Coverage for Workers with Disabilities Premium Notice | Form | pdf | 28 KB | |
| dma-5147 HCWD Denial for Non-Payment of Premium | Form | pdf | 21 KB | |
| dma-5148 HCWD Termination for Non-Payment of Premiums | Form | pdf | 22 KB | |
| dma-5149 HCWD Enrollment Fee Notice | Form | pdf | 11 KB | |
| dma-5150 Documentation of Passalong Eligibility or Ineligibility | Form | pdf | 11 KB | |
| dma-5150A Screening for Medicaid under the COLA Passalong | Form | pdf | 18 KB | |
| dma-5151 Health Coverage For Workers With Disabilities (HCWD) Medical Information Release Authorization | Form | pdf | 11 KB | |
| dma-5153 North Carolina Residency Applicant Declaration | Form | pdf | 12 KB | |
| dma-5153sp Declaración del solicitante de residencia en Carolina del Norte | Form | pdf | 78 KB | |
| dma-5154 County Transfer Letter | Form | pdf | 19 KB | |
| dma-5154-ia County Transfer Letter | Form | pdf | 31 KB | |
| dma-5155 Verification of Cash Value of Life Insurance | Form | pdf | 18 KB | |
| dma-5156 Statement of Outstanding Checks | Form | pdf | 11 KB | |
| dma-5157 Notice of Total Countable Resources; Right To Rebut Value | Form | pdf | 16 KB | |
| DMA-5157 SP Notice of Total Countable Resources; Right to Rebute Value | Form | pdf | 160 KB | |
| dma-5158 INCOME PRODUCING PROPERTY GUIDE | Form | pdf | 102 KB | |
| dma-5159 Statement of Intent to Return Home | Form | pdf | 12 KB | |
| dma-5160 Statement Of Spouse Or Dependent Relative In The Home | Form | pdf | 12 KB | |
| dma-5161 Transfer Of Asset Below Current Market Value Important Notice | Form | pdf | 24 KB | |
| dma-5167 County Analysis – Non-Compliance with Processing Thresholds or Thresholds for Denials, Withdrawals, Inquiries | Form | pdf | 383 KB | |
| dma-5168 Actions Taken On Improper Denials, Withdrawals, Or Inquiries Identified In Monitoring | Form | pdf | 177 KB | |
| dma-5169 Report Card Analysis | Form | pdf | 186 KB | |
| dma-5171 Approval Notice For Retroactive Medicaid Benefits | Form | pdf | 12 KB | |
| dma-5172 Erroneous Authorization Dates of Medicaid Eligibility | Form | pdf | 14 KB | |
| dma-5175 Marriage Verification | Form | pdf | 11 KB | |
| dma-5176 U.S. Citizenship Documentation Birth Certificate Request | Form | pdf | 12 KB | |
| dma-5178 U.S. Citizenship Documentation Desk Reference | Form | pdf | 37 KB | |
| dma-5180 SSI Check Terminated: Information Needed to Determine Medicaid Eligibility | Form | pdf | 336 KB | |
| dma-5181 Calculating Penalty Period – Transfers 11/1/07 or Later | Form | pdf | 19 KB | |
| dma-5182 Notice Of Cooperation In Establishing Paternity And Or Medical Support | Form | pdf | 13 KB | |
| dma-5183 Presumptive Eligibility Log | Form | pdf | 27 KB | |
| dma-5199-ia Medicaid Renewal Request for Information Notice | Form | pdf | 374 KB | |
| dma-5199sp-ia Aviso de pedido de información para la renovación de Medicaid | Form | pdf | 282 KB | |
| dma-5202A-ia Health Coverage from Jobs – Appendix A | Form | pdf | 677 KB | |
| dma-5202Asp-ia Apéndice A – Coberta de salud de empleos | Form | pdf | 241 KB | |
| dma-5202B-ia American Indian or Alaska Native Family Member (AI/AN) – Appendix B | Form | pdf | 37 KB | |
| dma-5202Bsp-ia Apéndice B – Miembro de la familia amerindio o nativo de Alaska (AI/AN) | Form | pdf | 167 KB | |
| dma-5202Csp-ia Apéndice C – Designación de representante autorizado | Form | pdf | 227 KB | |
| DMA-5202D-ia Income/Resources – Appendix D | Form | pdf | 702 KB | |
| DMA-5202DSp-ia Apéndice D – Ingresos/Recursos | Form | pdf | 308 KB | |
| DMA-7010 Reports of Referrals to Law Enforcement | Form | pdf | 71 KB | |
| DMA-7057 Referral For Investigation | Form | pdf | 14 KB | |
| DMA-7098-ia Request and Authorization to Disclose Health Information | Form | pdf | 47 KB | |
| DMA-9001 Carolina ACCESS Complaint Form Instructions | Form | pdf | 42 KB | |
| DMA-9002-ia CCNC/CA – Medical Exemption Request | Form | pdf | 60 KB | |
| DMA-9006 Carolina ACCESS Enrollment Form for Recipients of Medicaid and Health Choice | Form | pdf | 70 KB | |
| DMA-9006-ia Carolina ACCESS Enrollment Form | Form | pdf | 43 KB | |
| DMA-9007 Mail-In Application/Reenrollment Form | Form | pdf | 74 KB | |
| DMA-9008-SSI Recipient without Medicare | Form | pdf | 63 KB | |
| DMA-9009 SSI Recipient with Medicare | Form | pdf | 49 KB | |
| DMA-9010 County Transfer | Form | pdf | 53 KB | |
| DMA-9011 Change in Primary Doctor Practice | Form | pdf | 53 KB | |
| DMA-9012 Primary Care Provider Disenrolls Recipient | Form | pdf | 59 KB | |
| DMA-9013 Recipient with a Temporary Exempt | Form | pdf | 65 KB | |
| DMA-9016 CCNC/CA The Benefits of Being A Member-Medicaid | Form | pdf | 79 KB | |
| DMA-9016sp CCNC/CA: Las Ventajas de Ser Mirembro-Medicaid | Form | pdf | 16 KB | |
| DMA-9017 CCNC/CA: The Benefits of Being a Member-NCHC | Form | pdf | 118 KB | |
| DMA-9017sp CCNC/CA, Los Beneficios de Ser Miembro-NCHC | Form | pdf | 123 KB | |
| DMA-9050-ia Nursing Home Notice of Transfer/Discharge | Form | pdf | 77 KB | |
| DMA-9051-ia Nursing Home Hearing Request Form | Form | pdf | 69 KB | |
| DMA-9052-ia Adult Care Home Notice of Transfer/Discharge | Form | pdf | 85 KB | |
| DMA-9053-ia Adult Care Home Hearing Request Form | Form | pdf | 61 KB | |
| DSS-8110 CHANGE/TERMINATION ADEQUATE | Form | pdf | 133 KB | |
| DSS-8110 CHANGE/TERMINATION TIMELY | Form | pdf | 121 KB | |
| DSS-8110 CONTINUING | Form | pdf | 107 KB | |
| DSS-8110 Transitional | Form | pdf | 177 KB | |
| DSS-8110sp CHANGE/TERMINATION ADEQUATE | Form | pdf | 105 KB | |
| DSS-8110sp CHANGE/TERMINATION TIMELY | Form | pdf | 91 KB | |
| DSS-8110sp CONTINUING | Form | pdf | 134 KB | |
| DSS-8110sp Transitional | Form | pdf | 184 KB | |
