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NC Department of Health and Human Services

NC Division of
Medical Assistance

For Beneficiaries> Medicaid, Health Choice

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DHHS > DMA > For County Staff > Forms

Forms for County Staff

If you wish to view the forms in form number order, you may view them here.

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Community Care of North Carolina/Carolina ACCESS (CCNC/CA)

Eligibility Determination and Referral Forms

ABD Medicaid Parent to Child Deeming Budget Sheet
- Printer-Ready PDF Version (DMA-5008E)
- Interactive PDF Version (DMA-5008E-ia)
ABD Notice of Benefits
- Interactive PDF Version (DMA-5002-ia)
- Interactive PDF Version Spanish (DMA-5002sp-ia)
Additional Information Needed for Mail-In Application
- Printer-Ready PDF Version (DMA-5042)
- Interactive PDF Version (DMA-5042-ia)
Adult Budget Sheet (DMA-5008A)
Adult Mail-In Application Incomplete Letter
- Printer-Ready PDF Version (DMA-5104)
Adult Mail-In Application Log
- Printer Ready PDF Version (DMA-5105)
- Interactive PDF Version (DMA-5105-ia)
Adult Mail-In Application Verification Checklist
- Printer-Ready PDF Version (DMA-5015)
- Interactive PDF Version (DMA-5015-ia)
Authorization to Disclose Information (DMA-5028)
Buy-In Clerical Action
- Printer-Ready PDF Version (DMA-5004)
- Interactive PDF Version (DMA-5004-ia)
Certification of Need For Institutional Care for Individual Under Age 21 (DMA-5045)
Checklist for Ex Parte Review (DMA-5138)
Disability Determination Transmittal (DMA-4037)
Disclosure of Annuities (DMA-5110-ia)
Documentation of Need (DMA-5096)
- Interactive PDF Version (DMA-5096-ia)
Emergency Certification for Medicaid (DMA-5050-ia)
Family and Children Notice of Benefits
- Interactive PDF Version (DMA-5003-ia)
- Interactive PDF Version Spanish (DMA-5003sp-ia)
Family Planning Waiver New Enrollee Letter (DMA-3055)
Hardship - Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value) (DMA-5115-ia)
Hardship - Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets) (DMA-5113-ia)
Hardship - Request for Documentation for Undue Hardship Claim (DMA-5114-ia)
Informational Notice Regarding Annuities and Medicaid Eligibility (DMA-5112-ia)
LIS Verification Checklist
- Printer-Ready PDF Version (DMA-1051)
- Interactive PDF Version (DMA-1051-ia)
Log for NC Health Choice/Medicaid Mail-In Applications (DMA-5066)
Long Term Care Budget (DMA-5008b-ia)
Medical Assistance to the Aged, Blind and Disabled Redetermination Document
- Printer-Ready PDF Version (DMA-5007)
- Interactive PDF Version (DMA-5007-ia)
MAABD Redetermination for Aged, Blind, and Disabled Adult Categories
- Printer-Ready PDF Version (DMA-5007mr)
- Interactive PDF Version (DMA-5007mr-ia)
MAABD Mail Redeterminations - Verification Form
- Printer-Ready PDF Version (DMA-5007v)
- Interactive PDF Version (DMA-5007v-ia)
Mail-In Review for Help with Medicare Costs
- Printer-Ready PDF Version (DMA-5080)
- Interactive PDF Version (DMA-5080-ia)
Medicaid Application Pending (Other)
- Interactive PDF Version (DMA-5098-ia)
- Interactive PDF Version Spanish (DMA-5098sp-ia)
Medicaid Application Pending for Deductible
- Printer-Ready PDF Version (DMA-5099)
- Interactive PDF Version (DMA-5099-ia)
- Interactive PDF Version Spanish (DMA-5099sp-ia)
Medicaid Re-Enrollment Notice
- English (DMA-5077)
- Spanish (DMA-5077sp)
Medicaid Savings Program Notice (DMA-5060)
Medicaid/Work First Notice of Inquiry
- Printer-Ready PDF Version (DMA-5095)
- Interactive PDF Version (DMA-5095-ia)
- Interactive PDF Version Spanish (DMA-5095sp-ia)
Medical Provider Verification (DMA-5037)
MIC/NC Health Choice Budget Worksheet
- Printer-Ready PDF Version (DMA-5064)
- Interactive PDF Version (DMA-5064-ia)
NC Health Choice - Enrollment Fee Notice
- Printer-Ready PDF Version (DMA-5059)
- Interactive PDF Version (DMA-5059-ia)
Notice of Case Status
- Printer-Ready PDF Version (DMA-5020)
- Interactive PDF Version (DMA-5020-ia)
Notice of Overpayment for Medical Assistance
- English (DMA-8010)
- Spanish (DMA-8010sp)
Notification of Eligibility for Medicaid/Amount and Effective Date of Patient's Liability (DMA-5016-ia)
Notice of Transitional Benefits
- English (DMA-5083)
- Spanish (DMA-5083sp)
Notice on the Use of Social Security Numbers
- English (DMA-5001)
- Spanish (DMA-5001sp)
Presumptive Eligibility Transmittal Form

Reception Log (DMA-5093-ia)
Record of Medical Expenses Applied to the Deductible
- Printer-Ready PDF Version (DMA-5036)
Referral for Inpatient Hospital and Intermediate Care Facility in State Mental Hospital/State Mental Retardation Centers (DMA-5010-ia)
Referral to Local Social Security Office (DMA-5049-ia)
Report of Approval/Denial of LIS Application (DMA-1054)
Request Alien Emergency Days
Request Alien Medical Record
Request for Claims Override
Request for Information
- Printer-Ready PDF Version (DMA-5097)
- Interactive PDF Version (DMA-5097-ia)
- Printer-Ready PDF Version Spanish (DMA-5097sp)
- Interactive PDF Version Spanish (DMA-5097sp-ia)
Reserve History Sheet
- Printer-Ready PDF Version (DMA-5030)
- Interactive PDF Version (DMA-5030-ia)
Right to Rebut Value of Vehicles (DMA-5039)
Social Histiory Summary for the Disabled
- Printer-Ready PDF Version Social History Summary for the Disabled (DMA-5009)
- Interactive PDF Version Social History Summary for the Disabled (DMA-5009-ia)
Special Health Care Needs Questionnaire
- English (DMA-5069)
- Spanish (DMA-5069sp)
Spouse and Dependent Income Allowance Worksheet
- Printer-Ready PDF Version (DMA-5008C)
- Interactive PDF Version (DMA-5008C-ia)
Supplement BB to DMA-5063 Verification of Change in Situation (DMA-5063bb)
Transfer From SA to MA Form
- Printer-Ready PDF Version (DMA-5008D)
- Interactive PDF Version (DMA-5008D-ia)
Transitional Benefit Report
- Printer-Ready PDF Version (DMA-5082)
- Interactive PDF Version (DMA-5082-ia)
Transitional Benefits Good Cause
- English (DMA-5084)
- Spanish (DMA-5084sp)
Verification Form for Self-Employment Income and Expenses
- Printer-Ready PDF Version (DMA-5043)
- Interactive PDF Version (DMA-5043-ia)
Verification of Annuities (DMA-5111-ia)
Work First Family Assistance Termination/Denial Second Party Review Sheet

Estate Recovery

Medicaid and Health Choice Applications

Application for Assistance for Adult Medicaid
- Printer-Ready PDF Version (DMA-5000)
Family Planning Waiver Medicaid (FPW) Application Addendum
- Printer-Ready PDF Version (DMA-5063a)
- Interactive PDF Version (DMA-5063a-ia)
Health Check/NC Health Choice for Children Information and Application
- English Version (DMA-5063)
- Spanish Version (DMA-5063sp-ia)
Health Check/NC Health Choice for Children Re-Enrollment Information Sheet
- English (DMA-5063I)
- Spanish (DMA-5063Isp)
Health Check/NC Health Choice for Children Re-Enrollment Form
M-AF Supplement 2 - Use for Parent/Caretaker of Child Under 19, Children age 19 or 20, or Children Ineligible for MIC/NC Health Choice
Medical Assistance to the Aged, Blind and Disabled Redetermination Document
- Printer-Ready PDF Version (DMA-5007)
- Interactive PDF Version (DMA-5007-ia)
Notice of Incomplete Mail-in Application
Notice of Your Right to Apply for Benefits
- English (DMA-5094)
- Spanish (DMA-5094sp)
Verification/Eligibility Determination for Medical Assistance Applications Adult Categories
- Printer-Ready PDF Version (DMA-5008)
- Interactive PDF Version (DMA-5008-ia)

Medicare Part D Prescription Assistance Forms

Notice Of Approval for Extra Help with Medicare Perscription Drug Costs
- Printer-Ready PDF Version (DMA-1052)
- Interactive PDF Version (DMA-1052-ia)
Notice of Denial for Extra Help with Medicare Prescription Drug Costs
- Printer-Ready PDF Version (DMA-1053)
- Interactive PDF Version (DMA-1053-ia)

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Updated: October 23, 2012