DMA 9006
User Manual: 9006
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Division of Medical Assistance
Community Care of North Carolina/Carolina Access
DMA Fax 919-715-5235
DMA- 9006
Revised 02/ 2010
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: ______________________
