Get Dma5002

Filling out the Dma5002 form is an essential step for individuals seeking Medicaid or Special Assistance in North Carolina. This guide provides clear, step-by-step instructions for completing the form online, ensuring you understand each component and its requirements.

Follow the steps to successfully complete the Dma5002 form online.

1. Click the ‘Get Form’ button to access the Dma5002 form and have it open for editing.
2. Begin by entering the name of the County Department of Social Services in the designated field at the top of the form.
3. Complete the 'Date Mailed' section to indicate when this notification is sent out.
4. Fill in the approval section by stating the application for assistance details: the name of the applicant and the specific service being approved.
5. Record the Medicaid Identification number (MID) in the corresponding field. This number is crucial for verifying eligibility.
6. Indicate the eligibility dates for the stated service in the respective fields for start and end dates.
7. If applicable, list the patient monthly liability costs for long-term care for the designated months.
8. Document the Special Assistance payment amounts as required on the form, ensuring accurate entry for each relevant service category.
9. Indicate the start and end dates of Medicaid approval in the specified fields, ensuring no omissions.
10. Before finalizing, review all entries for accuracy and completeness. Once verified, you can save the changes, print, or share the form as needed.

Ensure you complete the Dma5002 form online to receive the assistance you need.