Get Dma 5124a

The Dma 5124a is an essential document for transportation providers seeking Medicaid funding in North Carolina. This guide will walk you through each section of the form to ensure a smooth and accurate completion process.

Follow the steps to successfully complete the Dma 5124a form online.

1. Click the ‘Get Form’ button to access the Dma 5124a form and open it in a suitable online editor.
2. Begin by entering the specific county where your Department of Social Services is located in the designated field.
3. Next, move to the results of the OIG Federal Inquiry section. Circle ‘No Match Found’ if applicable and provide any relevant details regarding the organization or business.
4. In the section for the name of the individual or entity that resulted in an exclusion match, fill in the appropriate information if any matches are found.
5. Record the exclusion code in the specified area, ensuring it is accurate.
6. Have the Transportation Coordinator or Designee sign in the signature field, followed by the date of completion.
7. Now, repeat these steps for the results of the NC DHHS Provider Penalty Tracking Database section, circling ‘No Match Found’ if applicable.
8. Enter any relevant details regarding the owner’s name and/or SSN if an exclusion is found, including the exclusion reason in the provided space.
9. Once all fields are completed, review the form for accuracy. You can now save changes, download, print, or share the form as needed.

Complete your Dma 5124a form online today for efficient processing.