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Forms for Medicaid Providers

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Medicaid and Health Choice Applications for Consumers

Forms on this page are in the PDF format unless noted. The free Adobe Acrobat Reader is required to view and print PDF files.

Frequently Used Forms

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MH/SA Targeted Case Management Letter of Attestation of Recipient Eligibility
Certification of Need: Medicaid Inpatient Psychiatric Services Under Age 21
Certification of Need: Psychiatric Residential Treatment Facility Service Under Age 21
Criterion V Request Form
Instructions for Use of Service Needs/Discharge Planning Status Form
Please refer to ValueOptions NC Medicaid for the latest version of the following forms and instructions for completing the forms.

CAP/Targeted Case Management (CTCM) Request for Authorization Form
Inpatient Treatment Report (ITR)
Outpatient Review Form (ORF2)

Breast and Cervical Cancer Medicaid

Breast and Cervical Cancer Medicaid Application (DMA-5079-ia)
Breast and Cervical Cancer Medicaid Application (DMA-5079sp-ia) - 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-ia)
Health Department BCCM Checklist (DMA-5087-ia)

Claims and Claim Adjustment

ADA Dental Claim Form - To order call 1-800-947-4746 or go online to www.adacatalog.org
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 Credit Balance Report
Medicaid Provider Refunds
- Medicaid Provider Refund Form (Excel format)
- Medicaid Provider Refund Form Instructions
Medicaid Resolution Inquiry
Medicare Crossover Reference Request
NCECSWeb Tool Logon ID and Password Change Request Form

Community Alternatives Program for Children (CAP/C)

CAP/C Letter of Understanding and Freedom of Choice (Word format)
CAP/C Case Manager Claims Review Note (Word format)
CAP/C Case Manager Quarterly Supporting Documentation Review Note (Word format)
CAP/C Case Manager Quarterly Visit Note (Word format)
CAP/C Contents of File (Word format)
CAP/C Cover Letter (Word format)
CAP/C Critical Incident Report (DMA-3201) (Word format)
CAP/C Note of Case Manager Contact with Recipient/Family/Caregiver/Legal Guardian (Word format)
CAP/C Notice of Voluntary Termination of Participation (Word format)
CAP/C Notice of Voluntary Withdrawl of Referral (Word format)
CAP/C Participation Discontinuation Notice (Word format)
CAP/C Participation Notice (Word format)
CAP/C Plan of Care, Part A (Word format)
CAP/C Plan of Care, Part B (Word format)
CAP/C Plan of Care, Part C (Word format)
CAP/C Referral Form (Word format)
CAP/C Service Authorization Discontinuation Notice (Word format)
CAP/C Service Authorization Notice (Excel format )
Note of Case Manager Contact with Provider (Word format)
Oral Nutrition Product Request Form
Verification of Employment for CAP/C

Community Care/Carolina ACCESS

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

Durable Medical Equipment (DME)

Oral Nutrition Product Request Form

HIV Case Management

HIV Contact Hours Approval Request Form

Home Health

Request for HCPCS Code Addition (DMA-3400)

Hospice

N.C. Medicaid Hospice Prior Approval Authorization Form

Local Education Agencies (LEA)

Certification of Non-Federal Match for Local Education Agencies

Medicaid Case Status

Notice of Case Status (DMA-5020)

MH/DD/SAS Health Plan Waiver Services (formerly Piedmont Cardinal Health Plan)

Money Follows the Person

Money Follows the Person Informed Consent Form:

Money Follows the Person Referral Form:

N.C. Health Choice

Nursing Facilities

Orthotics and Prosthetics

Outpatient Pharmacy Services

Outpatient Specialized Therpaies

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

Personal Care Services (PCS)

Presumptive Eligibility

Doctor's Statement of Due Date (DMA-5041)
Presumptive Eligibility Determination Form for Pregnancy - Related Care
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 (General)

Private Duty Nursing (PDN) Services

Radiology Services

Retro Request Fax Form

Third Party Insurance Forms

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Updated: May 17, 2013