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NC DHB »
Providers »
Forms »
Presumptive Eligibility Forms

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)

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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