Nursing Facility Forms

• Health Plan Notification of Nursing Facility Level of Care Form (NC Medicaid-2039)
• Nursing Facility Hearing Request Form (NC Medicaid-9051)
• Nursing Facility Notice of Transfer/Discharge (NC Medicaid-9050)
• North Carolina Level I Screening Form for Nursing Facility Admissions

NOTE: The following forms are found on the NCTracks Provider Prior Approval webpage

• Long-Term Care FL-2 (DMA372-124)
• Nursing Facility Notice of Transfer/Discharge Instructions
• Ventilator Physician's Order Form