Forms

Title Effective Date
DHB-2040 Tribal and Indian Health Services Jan 07, 2021 12:00 AM
DHB-2040B Tribal and Indian Health Services Sep 23, 2021 11:40 AM
DHB-2043 Third Party Recovery Accident Information Form Sep 17, 2019 03:40 PM
DHB-2055 Reimbursement for Medical Transportation May 17, 2022 04:25 PM
DHB-2056 Purchased Medical Transportation Costs May 09, 2022 09:05 AM
DHB-2193 Memorandum of CAP Waiver Enrollment Oct 21, 2020 10:25 AM
DHB-3051-ia Form and Instructions - Request for Independent Assessment for Personal Care Services - Attestation of Medical Need Jul 09, 2021 03:40 PM
DHB-4037 Disability Determination Transmittal Aug 08, 2017 03:20 PM
DHB-5001N Notice on the Use of Social Security Numbers Jun 09, 2009 03:20 PM
DHB-5001N_sp AVISO SOBRE EL USO DE LOS NÚMEROS DE SEGURO SOCIAL Feb 04, 2022 09:50 AM
DHB-5002 Important Notice About Your Medicaid or Special Assistance Approval Sep 27, 2021 01:30 PM
DHB-5002sp-ia Lea Este Importante Aviso Sobre Medicail o la Asistencia Especial Aviso de Aprobacion Jun 01, 2021 10:20 AM
DHB-5003 Medicaid or NC Health Choice Approval Notice Apr 01, 2022 09:50 AM
DHB-5003s-ia LEA ESTE IMPORTANTE AVISO SOBRE MEDICAID O NC HEALTH CHOICE AVISO DE APROBACION Sep 30, 2021 07:50 AM
DHB-5004-ia Buy-In Clerical Action Mar 31, 2022 09:00 AM
DHB-5016-ia Notification of Eligibility for Medicaid/Amount and Effective Date of Patient's Liability Jun 01, 2021 10:25 AM
DHB-5024 Transportation Assessment Notification May 09, 2022 09:10 AM
DHB-5024sp Aviso de Evaluación de Transporte May 09, 2022 09:10 AM
DHB-5028-ia Authorization to Disclose Information Feb 19, 2020 02:00 PM
DHB-5046 Notice of Rights/Responsibilities - Medical Transportation Assistance (English & Spanish) May 09, 2022 09:25 AM
DHB-5047 Medicaid Transportation Assessment May 09, 2022 09:30 AM
DHB-5048 Medicaid Transportation Exception Verification May 09, 2022 09:30 AM
DHB-5056 Estate Recovery Information Form Sep 10, 2019 03:05 PM
DHB-5059 NC Health Choice - Enrollment Fee Notice Sep 18, 2020 12:00 PM
DHB-5078 Medicaid Transportation Monitoring Report May 09, 2022 09:30 AM
DHB-5079 Breast and Cervical Cancer Medicaid Application Oct 01, 2020 12:00 AM
dhb-5079sp Solicitud de Medicaid para cáncer de seno y de cuello uterino Oct 01, 2020 12:00 AM
dhb-5081-ia Breast and Cervical Cancer Verification: Screening, Diagnosis and Treatment Oct 01, 2020 12:00 AM
dhb-5081r-ia Breast and Cervical Cancer Recertification: Screening, Diagnosis and Treatment Mar 23, 2021 12:00 AM
dhb-5081r-sp-ia Para Seguir Recibiendo Cobertura De Medicaid Para El Cancer De Seno Y El Cancer Del Cuello Uterino Mar 23, 2021 12:00 AM