NCDHHS policies and manuals logo

DHB Forms

TitleTypeFormatSize 
DHB-1061 Checklist for Child Medical Evaluation (CME) Reportingpdf291 KB
DHB-2039 PHP Notification of Nursing Facility Level of Carepdf239 KB
DHB-2040 Tribal and Indian Health Servicespdf155 KB
DHB-2040B Tribal and Indian Health Servicespdf189 KB
DHB-2043 Third Party Recovery Accident Information Formpdf797 KB
DHB-2044ia Medicaid Credit Balance Reportpdf189 KB
DHB-2045 Instructions for Completing Medicaid Credit Balance Reportpdf141 KB
DHB-2050 Voluntary Request to Terminate Medicaidpdf114 KB
DHB-2055 Reimbursement for Medical Transportationxls34 KB
DHB-2056 Purchased Medical Transportation Costsxls83 KB
DHB-2190 Internal Inspection Reportpdf483 KB
DHB-2191 Designation of Control Officer for FRR/Beer Reportspdf217 KB
DHB-2192 SSA Training Form – County Staff and County Contract Staffpdf95 KB
DHB-2193 Memorandum of CAP Waiver Enrollmentpdf253 KB
DHB-2194 IRC Rules Handoutpdf139 KB
DHB-2195 Documentation of Annual Security Training Confidentiality Form – County Staffpdf102 KB
DHB-2196 Documentation of Annual Security Training – Shred Contractor Trainingpdf103 KB
DHB-2197 FTI Record Keeping Logxls30 KB
DHB-2198 Log for Destruction of the FRR/BEER Reportspdf80 KB
DHB-2199 Documentation of the Visitation Logspdf45 KB
DHB-2200 Access Control Logpdf45 KB
DHB-2201 Confidentiality of Safeguard Datapdf140 KB
DHB-2202 Beneficiary Noticepdf79 KB
DHB-3051-ia Form and Instructions – Request for Independent Assessment for Personal Care Services – Attestation of Medical Needpdf494 KB
DHB-4037 Disability Determination Transmittalpdf165 KB
DHB-5001N Notice on the Use of Social Security Numberspdf107 KB
DHB-5001N_sp AVISO SOBRE EL USO DE LOS N√öMEROS DE SEGURO SOCIALpdf186 KB
DHB-5002 Important Notice About Your Medicaid or Special Assistance Approvalpdf768 KB
DHB-5002sp-ia Lea Este Importante Aviso Sobre Medicail o la Asistencia Especial Aviso de Aprobacionpdf296 KB
DHB-5003 Medicaid Approval Noticepdf349 KB
DHB-5003sp-ia LEA ESTE IMPORTANTE AVISO SOBRE MEDICAID AVISO DE APROBACIONpdf265 KB
DHB-5004-ia Buy-In Clerical Actionpdf201 KB
DHB-5008a Adult Budget Sheetpdf186 KB
DHB-5008B Supplement Bpdf118 KB
DHB-5008c-ia Spouse and Dependent Income Allowance Worksheetpdf62 KB
DHB-5008e ABD Medicaid Parent To Child Deeming Budgeting Sheetpdf221 KB
DHB-5009 Social History Summary For The Disabledpdf146 KB
DHB-5016-ia Notification of Eligibility for Medicaid/Amount and Effective Date of Patient’s Liabilitypdf140 KB
DHB-5024 Transportation Assessment Notificationpdf139 KB
DHB-5024sp Aviso de Evaluación de Transportepdf103 KB
DHB-5026 Notice Of Obligation To Apply For Veteran’s Benefitspdf105 KB
DHB-5027 Veteran’s Benefits Verification Letterpdf141 KB
DHB-5028-ia Authorization to Disclose Informationpdf259 KB
DHB-5036 Record Of Medical Expenses Applied To The Deductiblepdf218 KB
DHB-5043 Verification Form For Self-Employment Income and Expensespdf143 KB
DHB-5043-ia Verification Form For Self-Employment Income and Expensespdf79 KB
DHB-5046 Notice of Rights/Responsibilities – Medical Transportation Assistance (English & Spanish)pdf141 KB
DHB-5047 Medicaid Transportation Assessmentpdf323 KB
DHB-5048 Medicaid Transportation Exception Verificationpdf326 KB
DHB-5051 Estate Subject To Medicaid Recovery: Individuals Under Age 55pdf238 KB
DHB-5051sp Notice of Medicaid Recovery – People Under 55 (Spanish)pdf238 KB
DHB-5052 NOTICE: YOUR ESTATE IS SUBJECT TO MEDICAID RECOVERYpdf245 KB
DHB-5052 sp AVISO IMPORTANTE SU PATRIMONIO ESTÁ SUJETO A RECUPERACIÓN DE MEDICAIDpdf251 KB
DHB-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Noticepdf150 KB
DHB-5052SA-sp Notificación al Beneficiario de la Asistencia Especial Del Estado/Condado Sobre la Recuperación de los Gasto Médicos Pagados por Medicaidpdf207 KB
DHB-5053 Estate Recovery – Permanently Institutionalizedpdf151 KB
DHB-5053sp SU PATRIMONIO ESTÁ SUJETO A RECUPERACIÓN DE MEDICAIDpdf146 KB
DHB-5054 Estate Recovery – Claim Noticepdf165 KB
DHB-5054sp – Estate Recovery – Claim Notice (Spanish)pdf139 KB
DHB-5056 Estate Recovery Information Formpdf117 KB
DHB-5076 Pregnancy Management Programpdf76 KB
DHB-5076 Pregnancy Management Program -Spanish Versionpdf82 KB
DHB-5078 Medicaid Transportation Monitoring Reportpdf123 KB
DHB-5079 Breast and Cervical Cancer Medicaid Applicationpdf393 KB
dhb-5079sp Solicitud de Medicaid para c√°ncer de seno y de cuello uterinopdf404 KB
dhb-5081-ia Breast and Cervical Cancer Verification: Screening, Diagnosis and Treatmentpdf199 KB
dhb-5081r-ia Breast and Cervical Cancer Recertification: Screening, Diagnosis and Treatmentpdf150 KB
dhb-5081r-sp-ia Para Seguir Recibiendo Cobertura De Medicaid Para El Cancer De Seno Y El Cancer Del Cuello Uterinopdf146 KB
dhb-5081sp-ia Verificacion De Evaluacion, Diagnostico Y Tratamientopdf147 KB
dhb-5082 Transitional Benefit Reportpdf185 KB
dhb-5083 Notice of Transitional Benefitspdf199 KB
dhb-5083sp Aviso De Beneficios Transitoriospdf206 KB
dhb-5084 Transitional Benefits Good Causepdf149 KB
dhb-5084sp Motivos Justificados Para No Haber Entregado A Tiempo Su Informe De Beneficios Transitoriospdf136 KB
dhb-5087-ia Check List For Breast and Cervical Cancer Medicaidpdf192 KB
dhb-5087-sp Check List For Breast and Cervical Cancer Medicaidpdf91 KB
DHB-5097 Request for Informationpdf221 KB
DHB-5097sp-ia Solicitud de informaciónpdf186 KB
DHB-5098-ia Your Application for Medicaid is Pendingpdf21 KB
DHB-5104 Notice of Incomplete Applicationpdf114 KB
DHB-5104sp Notificación de Solicitud Incompletapdf135 KB
dhb-5106 Medicaid Pace Program Referralpdf280 KB
DHB-5111 Annuity Verification Formpdf115 KB
DHB-5113, Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets)pdf133 KB
DHB-5115 Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value)pdf163 KB
DHB-5118A-ia Medicaid Transportation Verification of Receipt of Covered Service – Apdf36 KB
DHB-5118B-ia Medicaid Transportation Verification of Receipt of Covered Service- Bpdf41 KB
DHB-5119 Denial of Transportation Request(s)pdf130 KB
DHB-5119sp Negación de Solicitudes de Transportepdf129 KB
dhb-5121 Determining Potential Medicaid Eligibilitypdf150 KB
DHB-5122 Community Spouse Resource Protection Worksheetpdf124 KB
DHB-5125 Medicaid Transportation No-Show Noticepdf80 KB
DHB-5125a Medicaid Transportation No-Show Final Noticepdf81 KB
DHB-5125Asp Aviso final: Usted no usó el transporte de Medicaidpdf173 KB
DHB-5125B Medicaid Transportation Suspension Noticepdf62 KB
DHB-5125Bsp Aviso de Suspensión de Transporte de Medicaidpdf122 KB
DHB-5125sp Aviso: Usted no usó el transporte de Medicaidpdf169 KB
DHB-5152 North Carolina Residency Declarationpdf129 KB
DHB-5152sp Declaración de residencia en Carolina del Nortepdf110 KB
DHB-5161 Transfer of Asset Below Current Market Valuepdf125 KB
DHB-5164 Change to PML Request Memopdf207 KB
DHB-5165 PACE Referral Request For A Medicaid Hearingpdf159 KB
DHB-5166 PACE Application Reportpdf180 KB
DHB-5170 Request for Claims Overridepdf242 KB
dhb-5179 MAABD Eligibility Overview Chartpdf277 KB
DHB-5181 5181 Calculating Penalty Period – Transfers 11/1/07 or Laterpdf110 KB
DHB-5200-ia Application for Health Coverage & Help Paying Costspdf916 KB
DHB-5200sp Solicitud Para Cobertura de Salud y Ayuda Para Pagar los Costospdf2 MB
DHB-5201-ia Application for Health Coverage & Help Paying Costs (Short Form)pdf568 KB
DHB-5202C-ia Designation of Authorized Representative – Appendix Cpdf155 KB
DHB-5202E-ia Medical Bills – Appendix Epdf215 KB
DHB-5202Esp-ia Apéndice E – Facturas médicaspdf119 KB
DHB-7058 Investigative Summarypdf1 MB
dhb-7059 Notice Of Change In Overpayment For Medical Assistancepdf94 KB
dhb-7060 Voluntarty Repayment Agreementpdf853 KB
dhb-7061 Voluntary Wage Withholding Agreementpdf173 KB
dhb-7063 Medicaid/NC Health Choice Recipient Profile Request Sheet Apr 21, 2021pdf298 KB
DHB-7078A Application 2nd Party Review Worksheetpdf528 KB
DHB-7078R Recertification 2nd Party Review Worksheetpdf515 KB
dhb-7097-ia Recipient Request and Authorization to Disclose Health Informationpdf175 KB
dhb-7098-I DMA-7098 – Additional Information and Instructions Feb 23, 2021pdf146 KB
dhb-8010 Notice of Overpayment For Medical Assistancepdf217 KB
dhb-8010sp Notice of Overpayment For Medical Assistance (Spanish Version)pdf131 KB
DHB-8020-ia Medicaid Eligibility Corrections Formpdf323 KB
DMA 9006sp Formulario de inscripción en CCNC/CApdf133 KB
dma-0100 Physician’s Signature for Authorization of Level of Carepdf89 KB
dma-1049 Cover Letter for LIS Application for Medicaidpdf12 KB
dma-1050 Notice of Application for Extra Help with Medicare Prescription Drug Costspdf13 KB
dma-1051 LIS Verification Checklistpdf65 KB
dma-1051-ia LIS Verification Checklistpdf170 KB
dma-1052 Notice of Approval for Extra Help with Medicaire Prescription Drug Costspdf28 KB
dma-1052-ia Notice of Approval for Extra Help with Medicare Prescription Drug Costspdf76 KB
dma-1053 Medicare Prescription Drug Subsidy Assistancepdf45 KB
dma-1053-ia Medicare Prescription Drug Subsidy Assistancepdf45 KB
dma-1054 Report of Approval/Denial of LIS Applicationpdf32 KB
dma-2000a County DSS Request for DMA Formspdf100 KB
dma-2000h Health Agencies Request for DMA Formspdf158 KB
dma-2000x Order Form for NC Medicaid Consumer Guidespdf82 KB
dma-2041-ia Third Party Recovery Insurance Informationpdf106 KB
dma-2046 Third Party Liability Medicaid and NC Health Choice Billing Guidepdf484 KB
dma-2053-ia Insurance Company Code Request Formpdf89 KB
dma-2057 Health Insurance Information Referral Formpdf5 KB
dma-2069 Health Insurance Premium Payment Program Applicationpdf140 KB
dma-2073 Medicaid Payment Information Requestpdf28 KB
dma-2073-I Instructions for Medicaid Payment Information Requestpdf17 KB
dma-2188 Notice of Privacy Practicespdf137 KB
dma-2188sp Aviso De Pr√°cticas De Privacidadpdf46 KB
dma-2190 Report of Internal Inspection FRR/BEERpdf717 KB
dma-2191 Designation of Control Officer for FRR/BEERpdf656 KB
dma-2192 Documentation of SSA Security Trainingpdf680 KB
dma-3002 Program Care Coordinator Pregnancy Outcome Reportpdf112 KB
dma-3004 Maternity Care Coordination Letter of Agreementpdf31 KB
dma-3005 Care Coordinator Appointment Recordpdf45 KB
dma-3006 Care Coordination Recordpdf165 KB
dma-3007-ia Family Care Coordination Planpdf207 KB
dma-3016 Care Coordination Narrative Sheetpdf44 KB
dma-3019 Individual Authorization Formpdf47 KB
dma-3047 Hysterectomy Statement Formpdf139 KB
dma-3050R Adult Care Home Personal Care Physicianpdf407 KB
dma-3055 Family Planning Waiver New Enrollee Letterpdf35 KB
dma-3055R-I Instructions for Completing the Revised Adult Care Home Personal Care Physician Authorization and Care Plan (DMA-3050R)pdf38 KB
dma-3057-ia North Carolina Community Alternatives Program for Children Participation Noticepdf97 KB
dma-3059-ia Sterilization Consent Formpdf242 KB
dma-3063-ia CAP/C – Physician’s Request Form for In-Home Nursing Servicespdf36 KB
dma-3065 PCS Medical Attestation for Licensed Care Home Residentspdf248 KB
dma-3066 PCS for Licensed ACH Residents – Independent Assessment request for New Residentspdf231 KB
dma-3072-ia Self-Assessment Toolspdf273 KB
dma-3073-ia Individual Risk Assessmentpdf41 KB
dma-3085-I- Session Law 2013-306 PCS Training Attestation Form DMA-3085pdf33 KB
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 ATTESTATIONpdf441 KB
dma-3114-I-ia Instructions – Request for Reconsideration of PCS Authorization (DMA-3114)pdf274 KB
dma-3114-ia Request for Reconsideration of PCS Authorizationpdf201 KB
dma-3116-I Instructions – Personal Care Services EPSDT Short-Term Increase-In-Hours Request Form (DMA-3116)pdf226 KB
dma-3116-ia Personal Care Services EPSDT Short-Term Increase-In-Hours Request Formpdf526 KB
dma-3125 Oral Nutrition Product Request Formpdf30 KB
dma-3136-ia Internal Quality Improvement Program Attestation Formpdf213 KB
dma-3136-ia-i Internal Quality Improvement Program Attestation Form – Instructionspdf32 KB
dma-3137 Personal Care Services (PCS) ICD-10 Transition Form Jun 01, 2018
dma-3137-i Personal Care Services (PCS) ICD-10 Transition Form – Instructionspdf298 KB
dma-3142-ia Abortion Statement (DMA-3142-IA)pdf127 KB
dma-3155 HIV Case Management – Medical Home Communication Trackerpdf543 KB
dma-3156 HIV Case Management – Continuing Education Hours Approval Formpdf684 KB
dma-3157 HIV Case Management Provider Recertification Application Checklistpdf213 KB
dma-3158 HIV Case Management Provider Recertification Applicationpdf128 KB
dma-3158-I HIV Case Management Provider Recertification Application – Instructionspdf189 KB
dma-3159 HIV Case Management Basic Training Request Formpdf173 KB
dma-3163-ia NC DMA – Community Alternatives Program for Children (CAP/C) Referral Formpdf523 KB
dma-3165-ia Notification of Hospice and Personal Care Services (PCS) Coordination Formpdf414 KB
dma-3171-I Verification of School Nursing – Instructionspdf346 KB
dma-3171-ia Verification of School Nursingpdf442 KB
dma-3172 Private Duty Nursing Employment Attestation Formpdf250 KB
dma-3173 Verification of Employment Formpdf153 KB
dma-3201-ia Critical Incident Report – Community Alternatives Program for Children (CAP-C)pdf298 KB
dma-3212-ia NC Medicaid Hospice Prior Approval Authorizationpdf110 KB
dma-3350 Prior Approval Form for Lower Extremity Prosthetic Component L5781 or L5782pdf25 KB
dma-3351 Prior Approval Form for Lower Extremity Prosthetic Component L5930pdf19 KB
dma-3352 Prior Approval Form for Lower Extremity Prosthetic Component L5968pdf20 KB
dma-3353 Prior Approval Form for Lower Extremity Prosthetic Component L5980pdf19 KB
dma-3354 Prior Approval Form for Lower Extremity Prosthetic Component L5987pdf19 KB
dma-3355 Prior Approval Form for Lower Extremity Prosthetic Component L5988pdf19 KB
dma-3400 Request for HCPCS Code Addition – Medicaid Home Health Fee Schedulepdf601 KB
dma-3504 Notice of Approval of Service Requestpdf243 KB
dma-3600 Tocolytic Prior Approval Request Formpdf34 KB
DMA-3611 Dupixent for Asthmapdf114 KB
dma-3701-ia N.C. Health Choice Extended Coveragepdf92 KB
dma-3701sp-ia Cobertura Extendida de NC Health Choicepdf64 KB
dma-372-124-ach-ia Adult Care Home FL2 Formpdf213 KB
dma-5001sp AVISO DEL USO DE NUMEROS DE SEGURO SOCIAL Feb 04, 2022
dma-5004 Buy-In Clerical Actionpdf204 KB
DMA-5008a North Carolina division of Medical Assistance Adult Budget Sheetpdf189 KB
dma-5008b-ia Long Term Care Budget Supplement B to DMA-5008pdf130 KB
dma-5008c Spouse and Dependent Income Allowance Worksheetpdf51 KB
dma-5008c-ia Spouse and Dependent Income Allowance Worksheetpdf63 KB
dma-5008e ABD Medicaid Parent to Child Deeming Budget Sheetpdf46 KB
dma-5008e-ia ABD Medicaid Parent to Child Deeming Budget Sheetpdf85 KB
dma-5009 Social History Summary for the Disabledpdf25 KB
dma-5009-ia Social History Summary for the Disabledpdf51 KB
dma-5010-ia Referral for Inpatient Hospital and Intermediate Care Facility in State Mental Hospital/State Mental Retardation Centerspdf474 KB
dma-5011-ia Managed Care Organization (MCO) Health Plan Welcome Letterpdf104 KB
dma-5011a CAP Indicator Letter (Memorandum)pdf11 KB
dma-5012 Managed Care Organization (MCO) Health Plan Transfer Letterpdf12 KB
dma-5020 Notice of Case Statuspdf77 KB
dma-5020-ia Notice of Case Statuspdf58 KB
dma-5022-ia Eligibility Information Systempdf160 KB
dma-5024sp-ia Notificacion de Solicitud de Transporte Jan 26, 2021
dma-5026 Notice of Obligation to Apply for Veteran’s Benefitspdf23 KB
dma-5027 Verification of VA Benefitspdf23 KB
dma-5031A Verification of Pregnancypdf27 KB
dma-5032 Presumptive Eligibility Determination Form for Pregnancy – Related Carepdf129 KB
dma-5032-(H) Presumptive Eligibility Determination by Hospitalpdf522 KB
dma-5032sp Formulario De Determinación De Elegibilidad Presunta Para Recibir Atención Relacionada Con El Embarazopdf43 KB
dma-5033 Presumptive Eligibility Transmittal Formpdf44 KB
dma-5033sp Formulario De Transmisión De Elegibilidad Presuntapdf26 KB
dma-5034 Presumptive Eligibility Income Checklistpdf149 KB
dma-5034sp Lista de Verification de Ingresos Para Elegibilidad Presuntapdf79 KB
dma-5035 Presumptive Eligibility Denialpdf78 KB
dma-5035sp Denegacion de Elegibilidad Presuntapdf17 KB
dma-5036 Record of Medical Expenses Applied to the Deductiblepdf200 KB
dma-5037 Medical Provider Verification Formpdf12 KB
dma-5039 Right to Rebut Value of Vehiclespdf11 KB
dma-5041 Doctor’s Statement of Due Datepdf16 KB
dma-5042 Mail-In Application, Additional Informationpdf11 KB
dma-5042-ia Additional Information Needed for Mail-In Applicationpdf29 KB
dma-5043 Self-Employment Income and Expenses Verification Formpdf20 KB
dma-5043-ia Self-Employment Income and Expenses Verification Formpdf81 KB
dma-5044 Consent for Release of Informationpdf22 KB
dma-5045 Certification of Need For Institutional Care for Individual Under Age 21pdf18 KB
dma-5049-ia Referral to Local Social Security Officepdf209 KB
dma-5050-ia Emergency Certification for Medicaidpdf73 KB
dma-5055-ia Third Party Resource Transmittalpdf16 KB
dma-5057 Explanation Of The Effect Of Transfer Of Asset (s) On Medical Assistance Eligibilitypdf30 KB
dma-5057sp Explicación De Los Efectos De La Transferencia De Activos Sobre La Elegibilidad Para Asistencia Médicapdf32 KB
dma-5058 Participating Telephone Service Providerspdf19 KB
dma-5066 NC Health Choice/Medicaid Mail-In Applications – Logpdf40 KB
dma-5066-ia NC Health Choice/Medicaid Mail-In Applications – Logpdf32 KB
dma-5069 Special Health Care Needs Questionnairepdf68 KB
dma-5069sp Cuestionario para Necesidades Especiades de Saludpdf99 KB
dma-5071i NC Health Choice Designation of Authorized Representative Formpdf62 KB
dma-5071sp NC Health Choice: Designación De Representante Autorizopdf86 KB
dma-5072i NC Health Choice First Level Review Request Formpdf174 KB
dma-5072sp Explicación Del Proceso De Revisión De Primer Nivelpdf62 KB
dma-5073-ia NC Health Choice – External Second Level Review Request Formpdf253 KB
dma-5073sp Explanación Del Proceso De Revisión De Segundo Nivelpdf270 KB
dma-5076 Pregnancy Medical Home Handoutpdf26 KB
dma-5076sp Folleto de Pregnancy Medical Homepdf22 KB
dma-5086 Request for Access to DHHS Provider Penalty Tracking Databasepdf70 KB
dma-5093-ia DAILY RECEPTION LOG FOR MEDICAL AND FINANCIAL ASSISTANCEpdf60 KB
dma-5094 Notice of Your Right to Apply for Benefitspdf36 KB
dma-5094sp Aviso de Su Derecho a Solicitar Beneficiospdf80 KB
dma-5095 Medicaid/Work First Notice of Inquirypdf102 KB
dma-5095-ia Medicaid/Work First Notice of Inquirypdf101 KB
dma-5095sp-ia Aviso De Indagacion Sobre Medicaid/Work Firstpdf72 KB
dma-5096-ia Documentation of Needpdf174 KB
dma-5097-ia Request for Informationpdf51 KB
dma-5097sp Solicitud de informaciónpdf41 KB
dma-5098sp-ia Su Solicitud Para Medicaid Esta Pendientepdf85 KB
dma-5100 Notice of Medicaid Redeterminationpdf20 KB
dma-5100sp Aviso De Redeterminación De Medicaidpdf20 KB
dma-5100sp Aviso De Redeterminación De Medicaidpdf29 KB
dma-5101 Notice of Approvalpdf28 KB
dma-5102 SSI Denialpdf20 KB
dma-5102sp Negación de SSIpdf20 KB
dma-5103D SSI Medicaid Denial Due to Refusal to Provide Health Insurance Informationpdf20 KB
dma-5103Dsp Denegación De Medicaid Por Medio De La Ssi Debido A La Negativa De Suministrar Información Sobre El Seguro De Saludpdf20 KB
dma-5103T SSA Medicaid Termination Due to Refusal to Provide Health Insurance Informationpdf20 KB
dma-5103Tsp Cancelación De Medicaid Por Medio De La Ssi Debido A La Negativa De Suministrar Información Sobre El Seguro De Saludpdf20 KB
dma-5105 Adult Mail-In Application Logpdf17 KB
dma-5105-ia Adult Mail-In Application Logpdf32 KB
dma-5108 Provider Transportation Recordpdf80 KB
dma-5109 Model No-Show Policy for Community Transportation Systemspdf116 KB
dma-5110-ia Disclosure of Annuitiespdf26 KB
dma-5111-ia Verification of Annuities Propertiespdf82 KB
dma-5112-ia Informational Notice Regarding Annuities and Medicaid Eligibilitypdf26 KB
dma-5113-ia Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets)pdf31 KB
dma-5114-ia Request for Documentation for Undue Hardship Claimpdf29 KB
dma-5115-ia Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value)pdf28 KB
dma-5122 Community Spouse Resource Protection Worksheetpdf142 KB
dma-5124 Medicaid Transportation Provider Documentationpdf31 KB
dma-5124a Medicaid Transportation Provider Documentation Addendumpdf84 KB
dma-5127 Notice of Reactivating The Health Check/Health Choice Programpdf55 KB
dma-5127sp Notice of Reactivating The Health Check/Health Choice Programpdf54 KB
dma-5128 Health Choice Enrollment & Waiting List Notificationpdf25 KB
dma-5128sp Registro de Health Choice & Lista de Espera Notificationpdf44 KB
dma-5131 FAX Request Form – From County DSS to EOIRpdf21 KB
dma-5132 FAX Request Form – From County DSS to USCISpdf24 KB
dma-5133 Emergency Medical Services Request for Informationpdf13 KB
dma-5134 Emergency Medical Services Request for Missing Informationpdf20 KB
dma-5135 Dates of Emergency Services Requested for an Alienpdf39 KB
dma-5141 Medicare/Medicare Part B Enrollment Advisory Letter (Automated)pdf27 KB
dma-5146 Health Coverage for Workers with Disabilities Premium Noticepdf28 KB
dma-5147 HCWD Denial for Non-Payment of Premiumpdf21 KB
dma-5148 HCWD Termination for Non-Payment of Premiumspdf22 KB
dma-5149 HCWD Enrollment Fee Noticepdf11 KB
dma-5150 Documentation of Passalong Eligibility or Ineligibilitypdf11 KB
dma-5150A Screening for Medicaid under the COLA Passalongpdf18 KB
dma-5151 Health Coverage For Workers With Disabilities (HCWD) Medical Information Release Authorizationpdf11 KB
dma-5153 North Carolina Residency Applicant Declarationpdf12 KB
dma-5153sp Declaración del solicitante de residencia en Carolina del Nortepdf78 KB
dma-5154 County Transfer Letterpdf19 KB
dma-5154-ia County Transfer Letterpdf31 KB
dma-5155 Verification of Cash Value of Life Insurancepdf18 KB
dma-5156 Statement of Outstanding Checkspdf11 KB
dma-5157 Notice of Total Countable Resources; Right To Rebut Valuepdf16 KB
DMA-5157 SP Notice of Total Countable Resources; Right to Rebute Valuepdf160 KB
dma-5158 INCOME PRODUCING PROPERTY GUIDEpdf102 KB
dma-5159 Statement of Intent to Return Homepdf12 KB
dma-5160 Statement Of Spouse Or Dependent Relative In The Homepdf12 KB
dma-5161 Transfer Of Asset Below Current Market Value Important Noticepdf24 KB
dma-5167 County Analysis – Non-Compliance with Processing Thresholds or Thresholds for Denials, Withdrawals, Inquiriespdf383 KB
dma-5168 Actions Taken On Improper Denials, Withdrawals, Or Inquiries Identified In Monitoringpdf177 KB
dma-5169 Report Card Analysispdf186 KB
dma-5171 Approval Notice For Retroactive Medicaid Benefitspdf12 KB
dma-5172 Erroneous Authorization Dates of Medicaid Eligibilitypdf14 KB
dma-5175 Marriage Verificationpdf11 KB
dma-5176 U.S. Citizenship Documentation Birth Certificate Requestpdf12 KB
dma-5178 U.S. Citizenship Documentation Desk Referencepdf37 KB
dma-5180 SSI Check Terminated: Information Needed to Determine Medicaid Eligibilitypdf336 KB
dma-5181 Calculating Penalty Period – Transfers 11/1/07 or Laterpdf19 KB
dma-5182 Notice Of Cooperation In Establishing Paternity And Or Medical Supportpdf13 KB
dma-5183 Presumptive Eligibility Logpdf27 KB
dma-5199-ia Medicaid Renewal Request for Information Noticepdf374 KB
dma-5199sp-ia Aviso de pedido de información para la renovación de Medicaidpdf282 KB
dma-5202A-ia Health Coverage from Jobs – Appendix Apdf677 KB
dma-5202Asp-ia Apéndice A – Coberta de salud de empleospdf241 KB
dma-5202B-ia American Indian or Alaska Native Family Member (AI/AN) – Appendix Bpdf37 KB
dma-5202Bsp-ia Apéndice B – Miembro de la familia amerindio o nativo de Alaska (AI/AN)pdf167 KB
dma-5202Csp-ia Apéndice C – Designación de representante autorizadopdf227 KB
DMA-5202D-ia Income/Resources – Appendix Dpdf702 KB
DMA-5202DSp-ia Apéndice D – Ingresos/Recursospdf308 KB
DMA-7010 Reports of Referrals to Law Enforcementpdf71 KB
DMA-7057 Referral For Investigationpdf14 KB
DMA-7098-ia Request and Authorization to Disclose Health Informationpdf47 KB
DMA-9001 Carolina ACCESS Complaint Form Instructionspdf42 KB
DMA-9002-ia CCNC/CA – Medical Exemption Requestpdf60 KB
DMA-9006 Carolina ACCESS Enrollment Form for Recipients of Medicaid and Health Choicepdf70 KB
DMA-9006-ia Carolina ACCESS Enrollment Formpdf43 KB
DMA-9007 Mail-In Application/Reenrollment Formpdf74 KB
DMA-9008-SSI Recipient without Medicarepdf63 KB
DMA-9009 SSI Recipient with Medicarepdf49 KB
DMA-9010 County Transferpdf53 KB
DMA-9011 Change in Primary Doctor Practicepdf53 KB
DMA-9012 Primary Care Provider Disenrolls Recipientpdf59 KB
DMA-9013 Recipient with a Temporary Exemptpdf65 KB
DMA-9016 CCNC/CA The Benefits of Being A Member-Medicaidpdf79 KB
DMA-9016sp CCNC/CA: Las Ventajas de Ser Mirembro-Medicaidpdf16 KB
DMA-9017 CCNC/CA: The Benefits of Being a Member-NCHCpdf118 KB
DMA-9017sp CCNC/CA, Los Beneficios de Ser Miembro-NCHCpdf123 KB
DMA-9050-ia Nursing Home Notice of Transfer/Dischargepdf77 KB
DMA-9051-ia Nursing Home Hearing Request Formpdf69 KB
DMA-9052-ia Adult Care Home Notice of Transfer/Dischargepdf85 KB
DMA-9053-ia Adult Care Home Hearing Request Formpdf61 KB
DSS-8110 CHANGE/TERMINATION ADEQUATEpdf133 KB
DSS-8110 CHANGE/TERMINATION TIMELYpdf121 KB
DSS-8110 CONTINUINGpdf107 KB
DSS-8110 Transitionalpdf177 KB
DSS-8110sp CHANGE/TERMINATION ADEQUATEpdf105 KB
DSS-8110sp CHANGE/TERMINATION TIMELYpdf91 KB
DSS-8110sp CONTINUINGpdf134 KB
DSS-8110sp Transitionalpdf184 KB