NCDHHS Policies and Manuals

NCDHHS Policies and Manuals > Divisional A-M > Health Benefits/NC Medicaid > HB Forms

HB Forms

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Title	Type	Format	Size
DHB-1061 Checklist for Child Medical Evaluation (CME) Reporting	Form	pdf	291 KB	Open Preview
DHB-2039 PHP Notification of Nursing Facility Level of Care	Form	pdf	239 KB	Open Preview
DHB-2040 Tribal and Indian Health Services	Form	pdf	155 KB	Open Preview
DHB-2040B Tribal and Indian Health Services	Form	pdf	189 KB	Open Preview
DHB-2043 Third Party Recovery Accident Information Form	Form	pdf	797 KB	Open Preview
DHB-2044ia Medicaid Credit Balance Report	Form	pdf	189 KB	Open Preview
DHB-2045 Instructions for Completing Medicaid Credit Balance Report	Form	pdf	141 KB	Open Preview
DHB-2050 Voluntary Request to Terminate Medicaid	Form	pdf	114 KB	Open Preview
DHB-2055 Reimbursement for Medical Transportation	Form	xls	34 KB	Open Preview
DHB-2056 Purchased Medical Transportation Costs	Form	xls	83 KB	Open Preview
DHB-2190 Internal Inspection Report	Form	pdf	483 KB	Open Preview
DHB-2191 Designation of Control Officer for FRR/Beer Reports	Form	pdf	217 KB	Open Preview
DHB-2192 SSA Training Form – County Staff and County Contract Staff	Form	pdf	95 KB	Open Preview
DHB-2193 Memorandum of CAP Waiver Enrollment	Form	pdf	253 KB	Open Preview
DHB-2194 IRC Rules Handout	Form	pdf	139 KB	Open Preview
DHB-2195 Documentation of Annual Security Training Confidentiality Form – County Staff	Form	pdf	102 KB	Open Preview
DHB-2196 Documentation of Annual Security Training – Shred Contractor Training	Form	pdf	103 KB	Open Preview
DHB-2197 FTI Record Keeping Log	Form	xls	30 KB	Open Preview
DHB-2198 Log for Destruction of the FRR/BEER Reports	Form	pdf	80 KB	Open Preview
DHB-2199 Documentation of the Visitation Logs	Form	pdf	45 KB	Open Preview
DHB-2200 Access Control Log	Form	pdf	45 KB	Open Preview
DHB-2201 Confidentiality of Safeguard Data	Form	pdf	140 KB	Open Preview
DHB-2202 Beneficiary Notice	Form	pdf	79 KB	Open Preview
DHB-3051-ia Form and Instructions – Request for Independent Assessment for Personal Care Services – Attestation of Medical Need	Form	pdf	494 KB	Open Preview
DHB-4037 Disability Determination Transmittal	Form	pdf	165 KB	Open Preview
DHB-5001N Notice on the Use of Social Security Numbers	Form	pdf	107 KB	Open Preview
DHB-5001N_sp AVISO SOBRE EL USO DE LOS N√öMEROS DE SEGURO SOCIAL	Form	pdf	186 KB	Open Preview
DHB-5002 Important Notice About Your Medicaid or Special Assistance Approval	Form	pdf	768 KB	Open Preview
DHB-5002sp-ia Lea Este Importante Aviso Sobre Medicail o la Asistencia Especial Aviso de Aprobacion	Form	pdf	284 KB	Open Preview
DHB-5003 Medicaid Approval Notice	Form	pdf	349 KB	Open Preview
DHB-5003sp-ia LEA ESTE IMPORTANTE AVISO SOBRE MEDICAID AVISO DE APROBACION	Form	pdf	265 KB	Open Preview
DHB-5004-ia Buy-In Clerical Action	Form	pdf	201 KB	Open Preview
DHB-5008a Adult Budget Sheet	Form	pdf	186 KB	Open Preview
DHB-5008B Supplement B	Form	pdf	118 KB	Open Preview
DHB-5008c-ia Spouse and Dependent Income Allowance Worksheet	Form	pdf	62 KB	Open Preview
DHB-5008e ABD Medicaid Parent To Child Deeming Budgeting Sheet	Form	pdf	221 KB	Open Preview
DHB-5009 Social History Summary For The Disabled	Form	pdf	146 KB	Open Preview
DHB-5016-ia Notification of Eligibility for Medicaid/Amount and Effective Date of Patient’s Liability	Form	pdf	140 KB	Open Preview
DHB-5024 Transportation Assessment Notification	Form	pdf	139 KB	Open Preview
DHB-5024sp Aviso de Evaluación de Transporte	Form	pdf	103 KB	Open Preview
DHB-5026 Notice Of Obligation To Apply For Veteran’s Benefits	Form	pdf	105 KB	Open Preview
DHB-5027 Veteran’s Benefits Verification Letter	Form	pdf	141 KB	Open Preview
DHB-5028-ia Authorization to Disclose Information	Form	pdf	259 KB	Open Preview
DHB-5036 Record Of Medical Expenses Applied To The Deductible	Form	pdf	218 KB	Open Preview
DHB-5043 Verification Form For Self-Employment Income and Expenses	Form	pdf	143 KB	Open Preview
DHB-5043-ia Verification Form For Self-Employment Income and Expenses	Form	pdf	79 KB	Open Preview
DHB-5046 Notice of Rights/Responsibilities – Medical Transportation Assistance (English & Spanish)	Form	pdf	141 KB	Open Preview
DHB-5047 Medicaid Transportation Assessment	Form	pdf	323 KB	Open Preview
DHB-5048 Medicaid Transportation Exception Verification	Form	pdf	326 KB	Open Preview
DHB-5051 Estate Subject To Medicaid Recovery: Individuals Under Age 55	Form	pdf	238 KB	Open Preview
DHB-5051sp Notice of Medicaid Recovery – People Under 55 (Spanish)	Form	pdf	238 KB	Open Preview
DHB-5052 NOTICE: YOUR ESTATE IS SUBJECT TO MEDICAID RECOVERY	Form	pdf	245 KB	Open Preview
DHB-5052 sp AVISO IMPORTANTE SU PATRIMONIO EST√Å SUJETO A RECUPERACI√ìN DE MEDICAID	Form	pdf	251 KB	Open Preview
DHB-5052sa State/County Special Assistance Beneficiary Estate Subject to Medicaid Recovery Notice	Form	pdf	150 KB	Open Preview
DHB-5052SA-sp Notificación al Beneficiario de la Asistencia Especial Del Estado/Condado Sobre la Recuperación de los Gasto Médicos Pagados por Medicaid	Form	pdf	207 KB	Open Preview
DHB-5053 Estate Recovery – Permanently Institutionalized	Form	pdf	151 KB	Open Preview
DHB-5053sp SU PATRIMONIO EST√Å SUJETO A RECUPERACI√ìN DE MEDICAID	Form	pdf	146 KB	Open Preview
DHB-5054 Estate Recovery – Claim Notice	Form	pdf	165 KB	Open Preview
DHB-5054sp – Estate Recovery – Claim Notice (Spanish)	Form	pdf	139 KB	Open Preview
DHB-5056 Estate Recovery Information Form	Form	pdf	117 KB	Open Preview
DHB-5076 Pregnancy Management Program	Form	pdf	76 KB	Open Preview
DHB-5076 Pregnancy Management Program -Spanish Version	Form	pdf	82 KB	Open Preview
DHB-5078 Medicaid Transportation Monitoring Report	Form	pdf	123 KB	Open Preview
DHB-5079 Breast and Cervical Cancer Medicaid Application	Form	pdf	393 KB	Open Preview
dhb-5079sp Solicitud de Medicaid para c√°ncer de seno y de cuello uterino	Form	pdf	404 KB	Open Preview
dhb-5081-ia Breast and Cervical Cancer Verification: Screening, Diagnosis and Treatment	Form	pdf	145 KB	Open Preview
dhb-5081r-ia Breast and Cervical Cancer Recertification: Screening, Diagnosis and Treatment	Form	pdf	63 KB	Open Preview
dhb-5081r-sp-ia Para Seguir Recibiendo Cobertura De Medicaid Para El Cancer De Seno Y El Cancer Del Cuello Uterino	Form	pdf	103 KB	Open Preview
dhb-5081sp-ia Verificacion De Evaluacion, Diagnostico Y Tratamiento	Form	pdf	159 KB	Open Preview
dhb-5082 Transitional Benefit Report	Form	pdf	185 KB	Open Preview
dhb-5083 Notice of Transitional Benefits	Form	pdf	199 KB	Open Preview
dhb-5083sp Aviso De Beneficios Transitorios	Form	pdf	206 KB	Open Preview
dhb-5084 Transitional Benefits Good Cause	Form	pdf	149 KB	Open Preview
dhb-5084sp Motivos Justificados Para No Haber Entregado A Tiempo Su Informe De Beneficios Transitorios	Form	pdf	136 KB	Open Preview
dhb-5087-ia Check List For Breast and Cervical Cancer Medicaid	Form	pdf	192 KB	Open Preview
dhb-5087-sp Check List For Breast and Cervical Cancer Medicaid	Form	pdf	91 KB	Open Preview
DHB-5097 Request for Information	Form	pdf	221 KB	Open Preview
DHB-5097sp-ia Solicitud de información	Form	pdf	186 KB	Open Preview
DHB-5098-ia Your Application for Medicaid is Pending	Form	pdf	21 KB	Open Preview
DHB-5104 Notice of Incomplete Application	Form	pdf	114 KB	Open Preview
DHB-5104sp Notificación de Solicitud Incompleta	Form	pdf	135 KB	Open Preview
dhb-5106 Medicaid Pace Program Referral	Form	pdf	280 KB	Open Preview
DHB-5111 Annuity Verification Form	Form	pdf	115 KB	Open Preview
DHB-5113, Notification of Right to Request an Undue Hardship Waiver (Transfer of Assets)	Form	pdf	133 KB	Open Preview
DHB-5115 Notification of Right to Request a Demonstrated Hardship Waiver (Home Equity Value)	Form	pdf	163 KB	Open Preview
DHB-5118A-ia Medicaid Transportation Verification of Receipt of Covered Service – A	Form	pdf	36 KB	Open Preview
DHB-5118B-ia Medicaid Transportation Verification of Receipt of Covered Service- B	Form	pdf	41 KB	Open Preview
DHB-5119 Denial of Transportation Request(s)	Form	pdf	130 KB	Open Preview
DHB-5119sp Negación de Solicitudes de Transporte	Form	pdf	129 KB	Open Preview
dhb-5121 Determining Potential Medicaid Eligibility	Form	pdf	150 KB	Open Preview
DHB-5122 Community Spouse Resource Protection Worksheet	Form	pdf	124 KB	Open Preview
DHB-5125 Medicaid Transportation No-Show Notice	Form	pdf	80 KB	Open Preview
DHB-5125a Medicaid Transportation No-Show Final Notice	Form	pdf	81 KB	Open Preview
DHB-5125Asp Aviso final: Usted no usó el transporte de Medicaid	Form	pdf	173 KB	Open Preview
DHB-5125B Medicaid Transportation Suspension Notice	Form	pdf	62 KB	Open Preview
DHB-5125Bsp Aviso de Suspensión de Transporte de Medicaid	Form	pdf	122 KB	Open Preview
DHB-5125sp Aviso: Usted no usó el transporte de Medicaid	Form	pdf	169 KB	Open Preview
DHB-5152 North Carolina Residency Declaration	Form	pdf	129 KB	Open Preview
DHB-5152sp Declaración de residencia en Carolina del Norte	Form	pdf	112 KB	Open Preview
DHB-5161 Transfer of Asset Below Current Market Value	Form	pdf	125 KB	Open Preview

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