Get Nc Dhb-5045 (formerly Dma-5045) 2019-2025
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How to fill out the NC DHB-5045 (Formerly DMA-5045) online
Filling out the NC DHB-5045 is an important step toward obtaining Medicaid coverage for individuals under age 21 who require institutional care. This guide will walk you through each section of the form, providing detailed instructions to ensure you complete it accurately and efficiently.
Follow the steps to complete the NC DHB-5045 form online.
- Click the ‘Get Form’ button to access the form in your online editor.
- In SECTION A, provide the name of the individual and their date of birth. Ensure this information is accurate, as it is crucial for processing the request for Medicaid coverage.
- The county department of social services (DSS) will fill in the details requesting the attending physician to complete SECTION B and SECTION C if necessary. Include the name of the county DSS and the caseworker’s information where indicated.
- In SECTION B, the attending physician will need to specify the primary and secondary diagnoses. They should also indicate the recommended duration of care and treatment for various facility types, marking the number of months as needed.
- For non-Medicaid facilities, the physician must specify the planned duration of care in months and provide additional documentation as required.
- Medical records and documentation must be attached if continuous care exceeds 12 months. Ensure all necessary medical records are enclosed, including specifics about treatment history and medications.
- The physician must indicate whether they will be treating the individual at the specified institution and complete SECTION C by providing their name, phone number, signature, and date.
- In SECTION D, an authorized agent from the DHB will determine financial eligibility. This section is completed by the DHB and requires the agent's name, title, signature, and date.
- After completing all sections, review the entire document for accuracy. Users can then save changes, download, print, or share the completed form.
Complete your NC DHB-5045 form online today and take the next step toward eligibility for Medicaid coverage.
The maximum income to qualify for Medicaid in North Carolina is determined by several factors, including family size and other eligibility criteria. Under the NC DHB-5045 (Formerly DMA-5045), these income thresholds can change yearly, so it’s essential to stay updated. Always refer to the latest information on the NC Medicaid website or consult with a professional for guidance. This can help ensure that you have all the necessary details to apply confidently.
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