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Get NC DHHS 3014/3056 2017-2024

Vision of Public Health Purchase of Medical Care Services 1907 Mail Service Center Raleigh, NC 27699-1900 ADAP 6.Diagnosis Code B20 7. Application Type/Requested Dates of Service 1. New Application (Immediate Coverage) Authorization Request/ Financial Eligibility 15. Applicant s County of Residence 16. Applicant s County Code (see Page 3) 17. Applicant s Street Address (Must match documentation of residence) 2. Summer Renewal (October 1 to March 31) 3. Winter Ren.

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