Get Nc Dma-5153 2011-2025
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How to fill out the NC DMA-5153 online
The NC DMA-5153 is a residency applicant declaration form required for establishing Medicaid eligibility in North Carolina. This guide provides clear and supportive instructions to help you complete the form accurately and efficiently online.
Follow the steps to complete the NC DMA-5153 form online.
- Click the ‘Get Form’ button to access the form and open it in the editor.
- In the provided case name field, enter the name associated with your case.
- Fill in your case ID in the designated area. Ensure that this number is accurate to avoid any processing issues.
- Next, input your worker number. This is typically assigned by your local Department of Social Services.
- In the declaration section, clearly print your full name to confirm your identity as the person making the declaration.
- Provide a statement declaring the inability to provide two North Carolina state residency verification documents as required.
- Carefully read the declaration statement concerning the accuracy of information provided and the implications of submitting false information.
- Sign the form in the designated signature area to authenticate your declaration.
- Enter the date of signing the document in the adjacent field.
- Complete the address section with your current residential details. This information is vital for contact purposes.
- Lastly, provide your telephone number to ensure that the Department can reach you if necessary.
- Once completed, review your entries for accuracy. After confirming that all information is correct, you can save changes, download, print, or share the form as needed.
Start completing the NC DMA-5153 online today to ensure your Medicaid application is processed smoothly.
The documents needed for Medicaid in North Carolina typically include proof of identity, income verification, and residency documentation. You will need items like Social Security cards, tax returns, and utility bills. Check the official requirements aligned with NC DMA-5153 to ensure you have all the necessary paperwork.
Fill NC DMA-5153
I understand that this declaration form is used to help verify that I meet North Carolina state residency requirements for Medicaid eligibility. Obsolete the DMA5153, North Carolina Residency Applicant Declaration form and removed from the online form library. Download North Carolina Residency Applicant Declaration (dma-5153) – Department of Health and Human Services (North Carolina) form. O Obsolete the DMA5153, North Carolina Residency Applicant Declaration form and removed from the online form library. The Medicaid Facilitator will Copy Everything and place copies in the file. 11. Auditor Should: Verify that there are two sources of acceptable verification or completed declaration (DMA5153) in the applicant's case file to. Residency and citizenship. DMA-5153 North Carolina Residency Applicant Declaration. Applicants who state they do not have two forms of residency documents, may sign this form. This means that health plans must have enough hospitals and providers in their network (group) for all members to get all covered services in a timely manner.
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