NC Medicaid NHA: User Access Request Form Submitted by ppark1 on Mon, 06/07/2021 - 10:38 This form can only be submitted by a Nursing Home Assessment (NHA) Coordinator Indicates required field User Type - Select -Add New UserUpdate UserRemove/Deactivate User WIRM Account Name Name First Name Middle Name Last Name Suffix Email Agency Position Title Phone Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code County - Select -AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYancey NHAGroup NHA User Role NHA Provider
