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Presumptive Eligibility Forms

  • Doctor's Statement of Due Date (DMA-5041)
  • Presumptive Eligibility Determination Form for Pregnancy - Related Care (DMA-5032)
     
  • Presumptive Eligibility Transmittal Form (DMA-5033)
  • Formulario de Transmisión de Elegibilidad Presunta (Presumptive Eligibility Transmittal Form in Spanish)
     
  • Presumptive Eligibility Income Checklist (DMA-5034)
  • Lista de verificatión de Ingresos Para Elegibilidad Presunta (Presumptive Eligibility Income Checklist in Spanish)
     
  • Presumptive Eligibility Denial (DMA-5035)
  • Denegación de Elegibilidad Presunta (Presumptive Eligibility Denial in Spanish)

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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.
 
Visit RelayNC for information about TTY services.
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