Skip all navigation Skip to page navigation

DHHS Home | A-Z Site Map | Get Updates | Divisions | About Us | Contacts | En Español

NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Forms for Medicaid Providers

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

 


Expand All Items Below
| Collapse Items Below

Administrative

Adult Care Homes

Effective October 1, 2013, all PCS referral/request forms were consolidated into the DMA 3051 Personal Care Services (PCS) Request for Services Form. With the implementation of DMA 3051, the following forms are no longer used:

  • DMA 3041 New Referral Request Form - Home Care Agency
  • DMA 3068 New Referral Request Form - Licensed Residential Facility
  • DMA 3042 Change of Status Request Form - Home Care Agency
  • DMA 3069 Change of Status Request Form - Licensed Residential Facility
  • DMA 3043 Change of Provider Request Form - Home Care Agency
  • DMA 3070 Change of Provider Request Form - Licensed Residential Facility

Below are all the currently used Adult Care Home forms:

Ambulance

Auditory Implant Sound Processors

Behavioral Health

Breast and Cervical Cancer Medicaid

Claims and Claim Adjustment

Community Alternatives Program for Children (CAP/C)

Community Alternatives Program for Disabled Adults (CAP/DA)

Community Care/Carolina ACCESS

Dental and Orthodontic Services

Durable Medical Equipment (DME)

Hearing Aid

HIV Case Management

Home Health

Hospice

Hysterectomy Statements Form

Local Education Agencies (LEA)

Medicaid Case Status

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

Money Follows the Person

Non-Covered Services

Nursing Facilities

Orthotics and Prosthetics

Outpatient Pharmacy Services

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)

Effective October 1, 2013, all PCS referral/request forms were consolidated into the DMA 3051 Personal Care Services (PCS) Request for Services Form. With the implementation of DMA 3051, the following forms are no longer used:

  • DMA 3041 New Referral Request Form - Home Care Agency
  • DMA 3068 New Referral Request Form - Licensed Residential Facility
  • DMA 3042 Change of Status Request Form - Home Care Agency
  • DMA 3069 Change of Status Request Form - Licensed Residential Facility
  • DMA 3043 Change of Provider Request Form - Home Care Agency
  • DMA 3070 Change of Provider Request Form - Licensed Residential Facility

Below are all the currently used PCS forms:

Presumptive Eligibility

Private Duty Nursing (PDN) Services

Radiology Services

Sterilization Consent Form

Third Party Insurance Forms

Visual Aids (Prior Approval)