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Reproductive Health Forms

Abortion

  • Abortion Statement Form (DMA-3214)

Hysterectomy

  • Hysterectomy Statements Form (DMA-3407)

  • Spanish Hysterectomy Statements Form (DMA-3407)

  • Spanish Fillable Form Hysterectomy Statements Form (DMA-3407)

Pregnancy Management Program

  • Pregnancy Risk Screening Form
  • English l Spanish

Sterilization

  • Sterilization Consent Form
  • English l Spanish

This page was last modified on 02/14/2023

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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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