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Hospice Forms

Notification of Hospice and Personal Care Services (PCS) Coordination Form (DMA-3165)

Note: These two forms can be found on the NCTracks Prior Approval web page:

  • Hospice Reporting Form (DMA-0004)
  • Hospice PA Authorization Form (DMA-3212)

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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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