Skip to main content
An official website of the State of North Carolina An official website of NC How you know

State Government websites value user privacy. To learn more, view our full privacy policy.

Secure websites use HTTPS certificates. A lock icon or https:// means you’ve safely connected to the official website.

Utility Menu
  • NC.GOV
  • NCDHHS
  • SERVICES
Home

Main menu

  • About NC Medicaid
    • About NC Medicaid
    • Division of Health Benefits Fellowship Programs
    • Eligibility
    • How To Apply
    • Copays
    • North Carolina Expands Medicaid
    • WHAT WE DO
  • Beneficiaries
    • Beneficiaries
    • Medicaid Recertification
    • 1915(i) Services
    • Servicios 1915(i) de Medicaid de Carolina del Norte
    • NC Innovations Waiver
    • Exención por innovaciones
    • Children and Families Specialty Plan
  • Find a Doctor
  • Providers
    • Providers
    • Programs and Services
    • Physician Administered Drug Program Catalog
    • Provider Enrollment
    • Program Specific Clinical Coverage Policies
    • Medicaid Bulletin
  • Reports
    • Reports
    • Wellness Visits, and Diagnostic and Treatment Services
    • Managed Care Program Annual Report (MCPAR)
    • NC Medicaid Enrollment Reports
    • Medicaid Expansion Dashboard
    • 1115 Demonstration Waiver Monitoring Reports
  • Meetings/Notices
  • Counties

Utility Menu

  • NC.GOV
  • NCDHHS
  • SERVICES
  1. Home
  2. Providers
  3. Forms

Reproductive Health Forms

Abortion

  • Abortion Statement Form (DMA-3142)

Hysterectomy

  • Hysterectomy Statements Form (DMA-3047)
  • Spanish Hysterectomy Statements Form (DMA-3047)
  • Spanish Fillable Form Hysterectomy Statements Form (DMA-3047)

Pregnancy Management Program

  • Pregnancy Risk Screening Form
  • English l Spanish

Sterilization

  • Sterilization Consent Form
  • English l Spanish

This page was last modified on 04/09/2024

Side Nav

  • About NC Medicaid
  • Beneficiaries
  • Find a Doctor
  • Providers
    • Programs and Services
    • Physician Administered Drug Program Catalog
    • Provider Enrollment
    • Program Specific Clinical Coverage Policies
    • Medicaid Bulletin
  • Reports
  • Meetings/Notices
  • Counties

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.
More

Follow Us

Network Menu

  • nc.gov
  • Website Feedback
  • Accessibility
  • Disclaimer & Terms of Use
  • Privacy Policy
  • Open Budget
Hosted on Digital Commons