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NC DHB »
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Forms »
Adult Care Home and Personal Care Services Forms

Adult Care Home and Personal Care Services Forms

Adult Care Home (ACH)

  • Adult Care Home FL-2 (DMA372-124)

Personal Care Services (PCS)

  • Request for Services and Instructions (DMA 3051)
  • Session Law 2013-306 PCS Training Attestation Form (DMA 3085-ia.pdf)
    • INSTRUCTIONS - Session Law 2013-306 PCS Training Attestation Form (DMA-3085-I.pdf)
  • Request for Reconsideration of PCS Authorization (DMA 3114-ia.pdf)
    • Instructions - Request for Reconsideration of PCS Authorization (DMA 3114-I-ia.pdf)
  • Quality Improvement Attestation Form (DMA 3136)
    • INSTRUCTIONS - Quality Improvement Attestation Form Instructions (DMA 3136-ia-i)
  • ICD-10 Transition Form (DMA 3137)
    • INSTRUCTIONS - ICD-10 Transition Form Instructions (DMA 3137-i)

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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