Get Nc Dhb-5048 2022-2025

The NC DHB-5048 form, officially known as the Medicaid transportation exception verification, is essential for individuals requiring transportation assistance for medical purposes. This guide will walk you through each step to effectively complete the form online, ensuring you provide all necessary details accurately.

Follow the steps to complete the NC DHB-5048 online effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, which is completed by the Department of Social Services, enter your county, date, beneficiary's name, address, date of birth, Medicaid ID, phone number, caseworker name, and caseworker phone number.
3. In Section 2, titled Medicaid beneficiary consent to release information, write your name as the beneficiary, and authorize the specified medical provider to release information to the Department of Social Services by filling in their details.
4. Sign and date the consent section, ensuring the signature is that of the Medicaid beneficiary or their representative.
5. Note that you should bring this form to your medical provider for completion and faxing to the DSS, as forms returned by the beneficiary directly are not accepted.
6. In Section 3, document the exception requested, mentioning if transportation is to a farther provider, a special mode is required, or if lodging is necessary.
7. Fill in the required details such as the provider's name, address, and phone number if applicable, explaining why the beneficiary cannot access nearby services.
8. Indicate any special needs or modes of transportation required and provide justification for these accommodations.
9. If lodging is necessary, explain why and specify the duration of stay near the facility.
10. Complete Section 4 by printing the name of the provider completing the form, their phone number, and obtaining their signature and date.
11. Finally, review your completed form for accuracy and save, download, print, or share it as needed.

Complete your NC DHB-5048 form online today to ensure you receive the necessary transportation assistance.