Form Dma-5095 - Medicaid/work First Notice Of Inquiry - North Carolina Department Of Social Services

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North Carolina ___________________________________County Department of Social Services
MEDICAID/WORK FIRST NOTICE OF INQUIRY
GENERAL INFORMATION AND REASON FOR INQUIRY (Caseworker completes)
1.
CASE NAME____________________________________CASE NO._______________________________DATE_____________________
ADDRESS_________________________________________________________________PHONE_________________________________
_____________________________________________________________________________________________________________________________________________
Worker’s Name_____________________________________________Telephone Number________________________________________
2.
Check the programs discussed with the applicant and the referrals made:
Discussed
Referred
Discussed
Referred
WFFA
MA, Adult
WFFA-EA
MIC
SA
MPW
FS
MQB
CIP
MAD
MAF
CAP
MAF Family Planning
: ______________________________________________________
OTHER
____________________________________________________________________________
____________________________________________________________________________
3. Document the reason for the inquiry. Explain why no application was filed. Specify the facts provided by the
applicant supporting the decision not to apply.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
INQUIRY STATEMENT
(Applicant Completes)
1. I understand I cannot receive benefits without filing an application.
2. I decided not to file an application for ______________________________because:
Program
___________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________
________________________________
Applicant’s Signature
Date
APPEAL RIGHTS: You have the right to appeal if DSS refuses to take your application or discourages you from applying for
assistance. Read the back of this notice to find out more about your appeal rights.
DMA-5095 (04-2007)

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