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COVID-19 Response

Resources, information and assistance from across state government. Visit the Information Hub
NC DHB »
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Community Care of NC/Carolina ACCESS Forms

Community Care of NC/Carolina ACCESS Forms



  • Instructions for enrolling Medicaid patients into CCNC/CA
    • CCNC/CA Enrollment form for Medicaid recipients
  • CA Medical Exemption Request (DMA-9002)
  • CA Hospital Admitting Agreement/Formal Arrangement
  • Medical Record Release for WIC Referral
  • Provider Confidential Information and Security Agreement
  • WIC Exchange of Information



Forms

  • HIEA Hardship Extension Forms
  • Provider/Stakeholder Request for Coverage Form

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Contact Information

NC Medicaid
Division of Health Benefits
2501 Mail Service Center
Raleigh, NC 27699-2501
 
NC Medicaid Contact Center
Phone: 888-245-0179
Monday-Friday 8 a.m. to 5 p.m.
Closed on State holidays. 
 
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