Division of Health Benefits (NC Medicaid)

State of North Carolina

Official Website: https://medicaid.ncdhhs.gov/

The Division of Health Benefits (NC Medicaid) helps low-income parents, children, seniors and people with disabilities receive physical and behavioral care and services to improve their health and well being.

Forms & Documents

Browse all Division of Health Benefits (NC Medicaid) government forms

1 - 20 of 22 forms

Form Title Topics
Adult Care Home FL-2 (DMA372-124)
CAP Referral Form 2021
CAP Retainer Payment Fact Sheet
Care Management for At-Risk Children Checklist Referral Form
Care Management for At-Risk Children Checklist Referral Form 2019
Care Management for High-Risk Pregnancies Pregnancy Risk Screening Form
Change Request Form (DHB-3511)
Consumer Direction Lite Fact Sheet
Discharge Summary Form (DHB-3513)
Documentaton Checklist
Home Health Certification and Plan of Care (CMS-485)
Instructions for Third Party Recovery (TPR) Accident Information Report (DMA-2043-I-ia)
INSTRUCTIONS - Quality Improvement Attestation Form Instructions (DMA 3136-ia-i)
Instructions - Request for Reconsideration of PCS Authorization (DMA 3114-I-ia.pdf)
INSTRUCTIONS - Session Law 2013-306 PCS Training Attestation Form (DMA-3085-I.pdf)
Medical Update Form (DHB-3509)
Referral Form (DHB-3508)
Request for Services and Instructions (DHB 3051)
School Reimbursement Form (DHB-3514)
Shared Case Form (DHB-3512)

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