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  • Basic Health And Medicaid Eligibility Review Form

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Y (HCA). Section 1: Household Information What language and dialect do you speak? Complete this section for member/applicant and legal spouse, even if not requesting coverage. Check here if you need an interpreter q WA Driver License or ID Number* Member/applicant s Last name First name Applicant signature (required) Race (see examples below)** Gender Requesting coverage q Male q Female q Yes q No Street address required; must attach proof* MI Social Security number.

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The county department of social services shall render a decision on an individual's application for Medicaid within 45 calendar days from the date of application, except for applications in which a disability determination has already been made or is needed.

The NCFAST-20020 is a prepopulated renewal form for the beneficiary to validate that current information remains the same or indicate changes and provide self-attestation of eligibility requirements, including income.

A North Carolina Medicaid prior authorization form is a document used by North Carolina-based medical professionals to request Medicaid coverage for a non-preferred drug. On the form, the person making the request must provide the medical justification for not prescribing a drug from the Preferred Drug List.

The Medically Needy Income Limit (MNIL) has remained the same for many years, and in 2023, continues to be $242 / month for a single individual and $317 / month for a married couple.

(1) A valid North Carolina drivers license or other identification card issued by the North Carolina Division of Motor Vehicles. (2) A current North Carolina rent or mortgage payment receipt, or current utility bill in the name of the applicant or the applicant's legal spouse showing a North Carolina address.

You or a family member might be eligible if you: Live in North Carolina and are a U.S. citizen or documented non-U.S. citizen. Meet income and resource guidelines. Are in one of these groups: Pregnant women. Children under age 21. Low-income individuals and families. Adults age 65 or older. Individuals with disabilities.

In 2023, a single individual applying for Nursing Home Medicaid in NC must meet the following criteria: 1) Have income under the Medicaid pay rate (est. to be between $6,381 / month and $9,087 / month).

a. A valid North Carolina drivers' license or other identification card issued by the North Carolina Division of Motor Vehicles. b. A current North Carolina rent, lease, or mortgage payment receipt, or current utility bill in the name of the applicant or the applicant's legal spouse, showing a North Carolina address.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232