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  • Dma-3136-iapdf Internal Quality Improvement Program Attestation Form

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Print Form N.C. Department of Health and Human Services Division of Medical Assistance INTERNAL QUALITY IMPROVEMENT PROGRAM ATTESTATION FORM Completed form should be submitted via email to NC Division.

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Under North Carolina law, to qualify for in-state residency, you must show that: You have established your legal residence (domicile) in North Carolina. You have maintained that domicile for at least twelve (12) consecutive months before the beginning of the term. You have a residentiary presence in the state.

Examples of these documents can include lease agreements, utility billings or receipts, and a current driver's license.

Prepare the following documents below for each person applying to help complete your application: Full legal name. Date of birth. Social Security number (or immigration documents) North Carolina residency. Income information (from paystubs, W-2 forms, tax returns or business records)

Proof you live in North Carolina, such as a photo ID with your address, a utility bill, a lease, or documentation of employment. Employer and income information for you and everyone in your household, such as paystubs, W-2 forms, tax returns or business records. Copies of all medical or life insurance policies.

An adult ages 19-64 may be eligible if the family income is $2,351/month or less. An adult ages 65+ may be eligible for full Medicaid if the family income is $1,704/month or less, and for other programs if the family income is $2,300/month or less. Additional requirements apply.

S-ABD, SSI cases Full Medicaid coverage only if a Medicaid application is submitted • Beneficiaries receiving Supplemental Security Income (SSI) -Federal cash assistance program for the aged, blind, and disabled, are automatically entitled to Medicaid. No separate application or Medicaid determination is required.

North Carolina Residency Any document issued by the state of North Carolina or a county or city in North Carolina or the federal government. North Carolina Vehicle Registration Card, insurance policy or title. North Carolina Voter Precinct Card. Military orders or military documents. Utility bill or cable bill.

(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.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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