NC DMA: County Forms

Division of Medical Assistance
Providing access to high quality, medically necessary health care for eligible North Carolina residents through cost effective purchasing of health care services and products.

Medicaid for
North Carolinians

Health Choice for Children

Medicaid Providers

DMA
Publications

County Forms

Community Care of North Carolina/Carolina ACCESS (CCNC/CA)
Eligibility Determination and Referral Forms
Estate Recovery
Medicaid and Health Choice Applications
Medicare Part D Prescription Assistance
SSI
Transportation
DMA Index for County DSS Forms Request (DMA-2000A)
DMA Index For N.C. Health Agencies Forms Request (DMA-2000H)

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

DMA Forms Main Page
DHHS Forms

Other Forms

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)
- Interactive PDF Version (DMA-5104-ia)
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-8046-ia)
County Transfer
- Printer-Ready PDF Version (DMA-5040)
- Interactive PDF Version (DMA-5040-ia)
Disability Determination Transmittal (DMA-4037)
Disability Determination Transmittal - HCWD (DMA-4037A)
Disclosure of Annuities (DMA-5110-ia)
Documentation of Need (DMA-5096)
- Printer-Ready PDF (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
- Printer-Ready PDF Version (DMA-5066)

Interactive PDF Version (DMA-5066-ia)

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)
- Printer-Ready PDF Version (DMA-5098)
- 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)
Presumptive Eligibility Transmittal Form

Reception Log (DMA-5093-ia)
Record of Medical Expenses Applied to the Deductible
- Printer-Ready PDF Version (DMA-5036)
- Interactive PDF Version (DMA-5036-ia)
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)
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 Forms

Medicaid and Health Choice Applications

Application for Assistance for Adult Medicaid
- Printer-Ready PDF Version (DMA-5000)
- Interactive PDF Version (DMA-5000-ia)
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
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 Application - Use for Parent/Caretaker of Child Under 19, Children age 19 or 20, or Children Ineligible for MIC/NC Health Choice Supplement 2
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
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)

SSI

Transportation Forms

Medicaid Transportation Assessment (DMA-5047-ia)
Medical Transportation Assistance Notice of Rights (DMA-5046) - English & Spanish
Medicaid Transportation Medical Necessity Verification
- Printer-Ready PDF Version (DMA-5048)
- Interactive PDF Version (DMA-5048-ia)
Reimbursement Request Form - Title XIX Transportation (DMA-2055-ia)
Transportation Request Notification
- Interactive PDF Version (DMA-5024-ia)
- Interactive PDF Version Spanish (DMA-5024sp-ia)
Title XIX Transportation Log
- Printer-Ready PDF Version (DMA-2056)
- Interactive PDF Version (DMA-2056-ia)

Last updated November 14, 2008