Forms

Note: The State-to-State Ambulance Transportation Addendum (372-118A) can be found on the NCTracks Prior Approval web page

Note: The Auditory Implant Sound Processor Request for Prior Approval can be found on the NCTracks Prior Approval Web Page.

  • MH/SA Targeted Case Management Letter of Attestation of Recipient Eligibility
  • Certification of Need: Medicaid Inpatient Psychiatric Services Under Age 21
  • Certification of Need: Psychiatric Residential Treatment Facility Service Under Age 21
  • Criterion V Request Form
  • Instructions for Use of Service Needs/Discharge Planning Status Form
  • Carolina ACCESS Office Visit Enrollment Form
  • CA Medical Exemption Request (DMA-9002)
  • CA Hospital Admitting Agreement/Formal Arrangement
  • Medical Record Release for WIC Referral
  • Provider Confidential Information and Security Agreement
  • WIC Exchange of Information for Women (with instructions)
  • WIC Exchange of Information for Infants and Children (with instructions)

The following dental forms are found on the NCTracks Prior Approval web page:  

  • Orthodontic Post Treatment Summary (DMA-0005)
  • Orthodontic Treatment Extension Request (DMA-0006)
  • Orthodontic Treatment Termination Request (DMA-0007)
  • Supplement to Dental Prior Approval Form (DMA-6602)