Frequently Used Forms

• CMS-1500 (HCFA-1500) Claim Form
• Electronic Funds Transfer (EFT) Authorization Agreement
• Fee Schedule Request
• Medicaid Claim Adjustment Request
• Medicaid Resolution Inquiry
• Medicare Crossover Reference Request
• Provider Change Form

Other Forms

• National Provider Identifier (NPI) Information and Collection Form
• Provider Enrollment
• Carolina ACCESS Provider Forms
• Consumer Forms
• County Forms
• Hearings and Appeals Forms
• Medicaid and Health Choice Applications
• Quality Assurance Forms
• Third Party Insurance Forms

Administrative Forms

• Fee Schedule Request
• Medicaid Credit Balance Report
• Notice of Change for Federally Qualified Health Clinic/Rural Health Center
• Provider Change Form
• Provider Visit Request
• Trading Partner Agreement
• W-9 Internal Revenue Service (IRS) (Request for Taxpayer Identification Number and Certification)

Adult Care Homes Forms

• Adult Care Home Special Care Unit-A Prior Approval Form and Instructions
• Adult Care Home Personal Care Services (PCS) Physician Authorization and Plan of Care (DMA-3050R)
• Adult Care Home Notice of Transfer/Discharge (DMA-9052)
• Adult Care Home Notice of Transfer/Discharge Instructions
• Individual Authorization (DMA-3019)

Ambulance Services Forms

• Prior Approval Form for Ambulance Services (372-118)
• State-to-State Ambulance Transportation Addendum

Baby Love/Maternity Care Coordination Services Forms

• Care Coordination Narrative Sheet (DMA-3016)
• Care Coordination Record (DMA-3006)
• Care Coordinator Appointment Record (DMA-3005)
• Family Care Coordination Plan (DMA-3007-ia)
• Maternity Care Coordination Letter of Agreement (DMA-3004)
• Program Care Coordinator Pregnancy Outcome Report (DMA-3002)

Behavioral Health Services Forms

• Certification of Need: Medicaid Inpatient Psychiatric Services Under Age 21
• Certification of Need: Psychiatric Residential Treatment Facility Service Under Age 21
• Inpatient Treatment Report (ITR) - Please refer to ValueOptions NC Medicaid for the latest version of the form and its instructions.
• Residential Authorization Form

Breast and Cervical Cancer Medicaid Forms

• Breast and Cervical Cancer Medicaid Application (DMA-5079)
• Breast and Cervical Cancer Medicaid Application (DMA-5079sp) - Spanish
• Breast and Cervical Cancer Recertification: Screening, Diagnosis and Treatment
  • English (DMA-5081r-ia)
  • Spanish (DMA-5081rsp)
• Breast and Cervical Cancer Verification: Screening, Diagnosis and Treatment
  • English (DMA-5081-ia)
  • Spanish (DMA-5081sp)
• Health Department BCCM Checklist (DMA-5087)

Claims and Claim Adjustment Forms

• ADA Dental Claim Form - To order call 1-800-947-4746 or go online to www.adacatalog.org
• CMS-1500 (HCFA-1500) Claim Form
• Certification of Signature on File
• Electronic Claims Submission (ECS) Agreement for Groups
• Electronic Claims Submission (ECS) Agreement for Individuals
• Electronic Funds Transfer (EFT) Authorization Agreement
• Medicaid Claim Adjustment Request
• Medicaid Provider Refunds
  • Medicaid Provider Refund Form (Excel format)
  • Medicaid Provider Refund Form Instructions
• Medicaid Resolution Inquiry
• Medicare Crossover Reference Request
• Pharmacy Claim Form

Comnmunity Alternatives Program for Children (CAP/C)

• CAP/C Assessment Form (Word format)
• CAP/C Cost Summary Form with formulas (Excel format)
• CAP/C Critical Incident Report (DMA-3201) (Word format)
• CAP/C Critical Incident Report (DMA-3201)
• CAP/C Critical Incident Report Instructions (DMA-3201i)
• CAP/C FL-2 Discrepancy Resolution Form (Word format)
• CAP/C Notice of Voluntary Termination of Participation (Word format)
• CAP/C Notice of Voluntary Withdrawl of Referral (Word format)
• CAP/C Nursing Respite/Home Modifications Tracking Worksheet (Word format)
• CAP/C Participation Discontinuation Notice (Word format)
• CAP/C Participation Notice (Word format)
• CAP/C Plan of Care Form (Word format)
• CAP/C Plan of Care, Sections G and H - Spanish (Word format)
• CAP/C Physician's Form (Word format)
• CAP/C Referral Form (Word format)
• CAP/C Service Authorization Discontinuation Notice (Word format)
• CAP/C Service Authorization Notice (Word format )

Community Intervention Services (CIS)

• CIS - Notification of Endorsement Action Update Form

Dental and Orthodontic Services

• ADA Dental Claim Form - To order call 1-800-947-4746 or go online to www.adacatalog.org
• Orthodontic Post Treatment Summary
• Orthodontic Treatment Extension Request
• Orthodontic Treatment Termination Request
• Supplement to Dental Prior Approval Form

Home Health

• Request for New Home Health Medical Supply (DMA-3400)

Home Infusion Therapy

• Tocolytic Prior Approval Request Form (DMA-3600)

Local Education Agencies

• Certification of Non-Federal Match for Local Education Agencies

Medicaid Case Status

• Notice of Case Status (DMA-5020)

Nursing Facilities

• North Carolina Level I Screening Form for Nursing Facility Admissions
• North Carolina Nursing Facilities Tracking Form
• Nursing Facility Capital Data Survey (Fair Rental Value)
• Nursing Facility Notice of Transfer/Discharge (DMA-9050)
• Nursing Facility Notice of Transfer/Discharge Instructions
• Nursing Facility Cost Report Software Package (DMA-4082)

Outpatient Pharmacy Services Forms

• Focused Risk Management (FORM) Medication Review Documents
• Focused Risk Management Program (FORM) Instructions
• Pharmacy Adjustment Request (372-200)
• Pharmacy Claim Form
• Pharmacy Online Request Form
• Prior Authorization Forms
• State Maximum Allowable Cost (SMAC) Pricing Inquiry Worksheet
• Synagis Policy and Forms 2008-2009
  • Policy and Procedures
  • Synagis For RSV Prophylaxis Form
  • Request for Medical Review for Synagis Outside of Criteria Form

Outpatient Specialized Therapies

• Prior Authorization is required through the Carolinas Center for Medical Excellence (CCME) . Visit the CCME website to obtain forms.

Personal Care Services (PCS) Forms

• PCS Corrective Action Plan Progress Report (Microsoft Word)
• PCS Corrective Action Plan Progress Report (PDF)
• PCS Initial Corrective Action Plan Form (Microsoft Word)
• PCS Initial Corrective Action Plan Form (PDF)
• PCS Physician Authorization for Certification and Treatment (PACT) (DMA-3000)
• PCS Physician Authorization for Certification and Treatment Instructions (DMA-3000-i)
• PCS-Plus Optional Nursing Assessment Worksheet (DMA-3000-B)
• PCS-Plus Request Form (DMA-3000-A)
• State Quality Assurance/Utilization Review Form
• State Quality Assurance/Utilization Review Form Instructions

Piedmont Cardinal Health Plan Forms

• Piedmont Cardinal Health Plan Transfer Letter (DMA-5012)
• Piedmont Cardinal Health Plan Welcome Letter (DMA-5011)

Presumptive Eligibility Forms

• Doctor's Statement of Due Date (DMA-5041)
• Presumptive Eligibility Determination Form for Pregnancy - Related Care
  • Printer-Ready PDF Version (DMA-5032)
  • Fillable PDF Version (DMA-5032-ia)
  • Fillable PDF Versin Spanish (DMA-5032s-ia)
• Presumptive Eligibility Transmittal Form (DMA-5033)
• Presumptive Eligibility Transmittal Form (DMA-5033sp) - Spanish
• Presumptive Eligibility Income Checklist (DMA-5034)
• Presumptive Eligibility Income Checklist (DMA-5034sp) - Spanish
• Presumptive Eligibility Denial (DMA-5035-ia)
• Presumptive Eligibility Denial (DMA-5035sp) - Spanish

Prior Approval Forms

• Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years of Age
• Prior Approval Form for MPW (372-118)
• Prior Approval Form for Ambulance Services (372-118)
• Pharmacy Prior Authorization Forms
• Private Duty Nursing Prior Approval Referral Form (DMA-3061)
• Supplement to Dental Prior Approval Form
• Tocolytic Prior Approval Request Form (DMA-3600)

Private Duty Nursing (PDN) Services Forms

• Hourly Nursing Review Criteria Form
• PDN Medical Update/Patient Inpatient Form (DMA-3062)
• PDN Physician's Request Form for Private Duty Nursing (DMA-3075)
• PDN Prior Approval Referral Form (DMA-3061)