The Child Medical Evaluation Checklist, Form DHB-1061 found on the NCDHHS website has been updated.
This link can also be accessed from the NC Medicaid Forms webpage.
Providers can access the updated Child Medical Evaluation Checklist Form by clicking on CMEP Form and then the words “Checklist for Child Medical Evaluation (CME) Reporting (DHB-1061).” Providers may choose to complete the form for each individual or pre-populate information on the site prior to printing the form. Signature fields may not be pre-populated.
Providers should always use the latest version when submitting the Child Medical Evaluation Checklist form to the NC Medicaid fiscal agent.
Contact
NCTracks Call Center, 800-688-6696 or NCTracksprovider@nctracks.com.