Fee Schedule Request Form

 

There is no charge for fee schedules requested from the Division of Medical Assistance (DMA). DMA Providers are expected to bill their usual and customary rate. Please note that fee schedules change regularly and you will be provided with the most current version upon receipt of your request.

If you are not able to download a fee schedule from the website, please use this document to request a fee schedule.

Requests for fee schedules can be mailed to:

     Division of Medical Assistance
     Financial Management/Rate Setting - Fee Schedules
     2501 Mail Service Center
     Raleigh, N. C. 27699-2501

Or fax your request to DMA’s Financial Management/Rate Setting section at (919) 814-0037.

Or E-mail your request to Muriel.Dean@dhhs.nc.gov
 
 
 
 
 
Name (Provider/Facility):
Provider Type:   Provider #:
E-Mail Address
Contact Person:   Phone #:
 
The requested fee schedule will be e-mailed in one of the following formats: Excel or Adobe PDF.
   
 
Last Modified Date: October 19, 2012