Get Nc Dhb-5118a 2022-2025

The NC DHB-5118A form is essential for documenting the receipt of Medicaid-covered transportation services. This guide provides a clear, step-by-step approach to successfully completing the form online, ensuring that all necessary information is accurately recorded.

Follow the steps to complete the NC DHB-5118A online.

1. Use the ‘Get Form’ button to obtain the NC DHB-5118A form and open it in your chosen digital editor.
2. Begin by filling in the Medicaid recipient’s name and Medicaid ID number in the designated fields at the top of the form.
3. Next, enter the date when the transportation assistance was provided, ensuring it matches the date of the Medicaid-covered service.
4. Provide the name of the Medicaid provider or facility where the service was rendered in the appropriate section.
5. Print your name clearly in the field for the individual completing the form, followed by their contact phone number.
6. Lastly, sign the form in the space designated for the signature of the person completing it.
7. After verifying all entries for accuracy, choose to save the changes, download the completed form, print it, or share it with relevant parties as needed.

Complete the NC DHB-5118A form online today to ensure proper documentation of Medicaid services.