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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

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  • About NC Medicaid
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  • Providers
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    • Medicaid Bulletin
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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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