Forms

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

Medicaid transportation reimbursement request form - DMA-2055

     NOTE: The following forms can be found on the NCTracks Provider Prior Approval web page

  • Long-Term Care FL-2
  • Nursing Facility Notice of Transfer/Discharge Instructions
  • Ventilator Physician's Order Form