DMA 9006
User Manual: 9006
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Case #_____________ Dist. # _____________ CCNC/CA Enrollment Form Date: __________ County: _________ Fax: ________________ Person Completing Form: _____________________ Case Head: ____________________________MID__________________ Preferred Language: __________________ Address: _____________________________________________________________________________________________ Street City Zip Telephone #: _____________________ Cell # ___________________ Email: ______________________________ Person to be Enrolled Date of Birth Medicaid/NCHC ID Name of primary care provider Provider ID or Exempt Code 1 2 3 4 5 If requesting a temporary exemption for anyone above, write the recipient’s ID number and provide a detailed reason for the request. Attach additional paper if necessary. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ (Medicaid) CCNC/CA Handbook provided at time of interview. CCNC/CA Handbook mailed to Case head. “CCNC/CA: The Benefits of Being a Member-Medicaid” Handout (Figure 12a) provided at time of interview. “CCNC/CA: The Benefits of Being a Member-Medicaid” Handout (Figure 12a) mailed to Case head. (NCHC) “The Benefits of Being a Member-NCHC” Handout (Figure 12b) provided at time of interview. “The Benefits of Being a Member-NCHC” Handout (Figure 12b) mailed to Case head. SIGNATURE OF PATIENT OR HEAD OF HOUSEHOLD IF PATIENT IS A MINOR: ______________________________________________ DATE: __________________ (By signing, I certify that I have received an explanation of CCNC/CA and have been given the opportunity to choose a participating medical home.) FOR STATE USE ONLY Exemption Denied Exemption Approved Exempt Code: ______________________ Division of Medical Assistance Community Care of North Carolina/Carolina Access DMA Fax 919-715-5235 DMA- 9006 Revised 02/ 2010
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