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Forms for Medicaid Providers

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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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Administrative

Adult Care Homes

Ambulance

Baby Love and Maternity Care Coordination

Behavioral Health

Certification of Need: Medicaid Inpatient Psychiatric Services Under Age 21
Certification of Need: Psychiatric Residential Treatment Facility Service Under Age 21
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
Criterion V Request 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)
Health Department BCCM Checklist (DMA-5087)

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 Provider Refunds
- Medicaid Provider Refund Form (Excel format)
- Medicaid Provider Refund Form Instructions
Medicaid Resolution Inquiry
Medicare Crossover Reference Request

Community Alternatives Program for Children (CAP/C)

CAP/C Assessment Form (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 Cost Summary Form with formulas (Excel format)
CAP/C Critical Incident Report (DMA-3201) (Word format)
CAP/C Critical Incident Report (DMA-3201)
CAP/C FL-2 Discrepancy Resolution Form (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 Nursing Respite/Home Modifications Tracking Worksheet (Word format)
CAP/C Participation Discontinuation Notice (Word format)
CAP/C Participation Notice (Word format)
CAP/C Plan of Care Form (Word format)
CAP/C Plan of Care, Sections G and H - Spanish (Word format)
CAP/C Physician's Form (Word format)
CAP/C Referral Form (Word format)
CAP/C Service Authorization Discontinuation Notice (Word format)
CAP/C Service Authorization Notice (Word format )
CAP/C Respite Service Authorization Notice (Word format )
Oral Nutrition Product Request Form
Note of Case Manager Contact with Provider (Word format)

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

Home Health

Request for HCPCS Code Addition (DMA-3400)

Home Infusion Therapy

Tocolytic Prior Approval Request Form (DMA-3600)

Local Education Agencies (LEA)

Certification of Non-Federal Match for Local Education Agencies

Medicaid Case Status

Notice of Case Status (DMA-5020)

Money Follows the Person

Nursing Facilities

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)

Piedmont Cardinal Health Plan

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: December 4, 2009