Forms

A    B    C    D    E    H    M    N    O    P    R    S    T    U-Z   

CATEGORY FORM DESCRIPTIONS
Abortion Physician statement for therapeutic abortion services
Adult Care Homes Plan, serve and document quality of care for individuals residing in adult care homes
Ambulance Prior approval and state-to-state medical transportation
Auditory Processing Prior approval for auditory implant sound processors
Behavioral Health Mental health and substance use targeted case management, certificates of need, individual service needs and discharge planning
Breast and Cervical Cancer Breast and cervical cancer, including application for coverage, certification and verification of the condition
Community Alternative Programs (CAP) CAP for Children (CAP-C) and CAP for Disabled Adults (CAP-DA)
Community Care of NC/Carolina ACCESS (CCNC/CA) CCNC/CA, including office visit enrollment, medical exemption request, hospital admitting agreement and confidentiality agreement
Dental and Orthodontic Dental/orthodontic services, including prior approval, treatment extension, treatment termination and post-treatment summaries
Direct Enrolled Outpatient Behavioral Health Independent mental health and substance use provider reviews
Durable Medical Equipment (DME) Durable medical equipment, including prior approval for general and specialized products
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Request non-covered Medicaid plan services for beneficiaries under the age of 21
Hearing Loss Providing hearing aids
HIV Case Management Targeted case management for beneficiaries living with HIV/AIDS
Home Health Prior approval home health, and HCPCS Code Addition Medicaid Home Health Fee Schedule
Hospice Hospice services, including prior approval, documentation and coordination with personal care service provision
Hysterectomy Hysterectomy informed consent
Medical Transportation Ambulance and Non-Emergency Medical Transportation (NEMT)
Mental Health/Developmental Disabilities/Substance Abuse Forms related to behavioral health, direct enrolled outpatient behavioral health and mental health/substance use targeted case management
Non-Emergency Medical Transportation Provider request for reimbursement of services rendered
Nursing Facilities Plan, serve and document quality of care for individuals residing in skilled nursing facilities
Orthodontics Orthodontic services, including prior approval, treatment extension, treatment termination and post-treatment summaries
Orthotics and Prosthetics Orthotic and prosthetic equipment, including prior approval for general and specialized products
Personal Care Services  Plan, serve and document quality of care for individuals obtaining personal care services
Pregnancy Medical Home Pregnancy risk assessment
Presumptive Eligibility Hospital presumptive eligibility, giving temporary Medicaid or CHIP coverage to those likely to qualify for benefits
Private Duty Nursing Plan, serve and document quality of care for individuals getting private duty nursing
Radiology Retroactive eligibility for radiology services request
Reproductive Health Abortion, hysterectomy, pregnancy medical home and sterilization
Sterilization Sterilization informed consent
Third-Party Liability  Third-party insurance