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Get Dma 9006
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How to fill out the Dma 9006 online
The Dma 9006 form is an essential enrollment document for community care services in North Carolina. This guide will provide clear, step-by-step instructions to help users complete the form online with ease.
Follow the steps to complete the Dma 9006 form online.
- Click ‘Get Form’ button to access the Dma 9006 form and open it in your editor.
- Complete your personal information by filling in the date, county, and fax number. Ensure that you enter the name of the person completing the form.
- Provide the case head's name and MID in the designated fields. Additionally, select your preferred language.
- Fill in the address section accurately, including street, city, and zip code.
- Enter the telephone number, cell number, and email address for contact purposes.
- List the person to be enrolled along with their date of birth and MID in the given fields.
- Provide the name of the primary care provider and their corresponding provider ID or exemption code.
- If you are requesting a temporary exemption for anyone listed, enter their number and offer a detailed reason for the request. Use additional paper if necessary.
- Indicate whether a handbook was provided and complete the signature section. If the patient is a minor, the head of the household must sign, and the date of the signature must be provided.
- Review all entries for accuracy before proceeding to save changes, download, print, or share the completed form.
Begin your enrollment process by completing the Dma 9006 form online today.
NC Medicaid Managed Care Health Plans. Behavioral Health I/DD Tailored Plans. EBCI Tribal Option. Health Plan Contracts.
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