Forms

Title Effective Date
dma-5132 FAX Request Form - From County DSS to USCIS Jun 22, 2011 10:40 AM
dma-5133 Emergency Medical Services Request for Information Oct 19, 2011 10:40 AM
dma-5134 Emergency Medical Services Request for Missing Information Oct 19, 2011 10:40 AM
dma-5135 Dates of Emergency Services Requested for an Alien Jul 18, 2015 10:50 AM
dma-5141 Medicare/Medicare Part B Enrollment Advisory Letter (Automated) Apr 10, 2012 11:20 AM
dma-5146 Health Coverage for Workers with Disabilities Premium Notice Mar 04, 2014 11:20 AM
dma-5147 HCWD Denial for Non-Payment of Premium Mar 04, 2014 11:20 AM
dma-5148 HCWD Termination for Non-Payment of Premiums Mar 04, 2014 11:25 AM
dma-5149 HCWD Enrollment Fee Notice Oct 24, 2013 11:25 AM
dma-5150 Documentation of Passalong Eligibility or Ineligibility Oct 13, 2011 11:25 AM
dma-5150A Screening for Medicaid under the COLA Passalong Mar 01, 2012 11:25 AM
dma-5151 Health Coverage For Workers With Disabilities (HCWD) Medical Information Release Authorization Oct 13, 2011 11:45 AM
dma-5152 North Carolina Residency Declaration Feb 29, 2016 11:50 AM
dma-5152sp Declaración de residencia en Carolina del Norte Nov 08, 2012 11:50 AM
dma-5153 North Carolina Residency Applicant Declaration Oct 13, 2011 11:50 AM
dma-5153sp Declaración del solicitante de residencia en Carolina del Norte Nov 08, 2012 11:55 AM
dma-5154 County Transfer Letter Nov 17, 2011 12:00 PM
dma-5154-ia County Transfer Letter Nov 17, 2011 12:00 PM
dma-5155 Verification of Cash Value of Life Insurance Oct 13, 2011 12:00 PM
dma-5156 Statement of Outstanding Checks Dec 13, 2011 12:00 PM
dma-5157 Notice of Total Countable Resources; Right To Rebut Value Oct 13, 2011 12:05 PM
DMA-5157 SP Notice of Total Countable Resources; Right to Rebute Value Aug 20, 2020 12:05 AM
dma-5158 INCOME PRODUCING PROPERTY GUIDE Mar 07, 2012 12:05 PM
dma-5159 Statement of Intent to Return Home Oct 13, 2011 12:05 PM
dma-5160 Statement Of Spouse Or Dependent Relative In The Home Oct 13, 2011 12:30 PM
dma-5161 Transfer Of Asset Below Current Market Value Important Notice Oct 13, 2011 12:40 PM
dma-5164 Change to PML Request Memo to DMA Claims Analysis Unit Apr 05, 2016 12:40 PM
dma-5167 County Analysis – Non-Compliance with Processing Thresholds or Thresholds for Denials, Withdrawals, Inquiries Nov 01, 2017 12:45 PM
dma-5168 Actions Taken On Improper Denials, Withdrawals, Or Inquiries Identified In Monitoring Nov 01, 2017 12:45 PM
dma-5169 Report Card Analysis Nov 01, 2017 12:45 PM