Form Dma-5004 - Buy-In Clerical Action - North Carolina Department Of Health And Human Services
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1
2Department of Health and Human Services
Division of Medical Assistance
BUY-IN CLERICAL ACTION
DO NOT SEND THIS FORM UNTIL THE
. __________________________
CLIENT’S MEDICARE ENTITLEMENT
County DSS
Part I
(County Name)
HAS BEEN VERIFIED
1.
Complete all of Part I. Missing information will result in the form not being processed and returned.
❐
❐
❐
2.
Action Needed
Add to Part B Buy-In
Add to Part A Buy-In
SSI:
Yes
(“Q” Class recipients only)
❐
❐
❐
Delete
Correct Eff. Date to____________________
No
3.
_______ Aid Program ________Aid Category________ Classification
____________________Medicaid I.D. Number
4.
5.
________________________________ ___________________________
__________
_____________________
__________
Last Name
First Name
MI
SS Claim No.
Suffix
6.
Address
___________________________________________________________
___________________________________________________________
______________
_____
__________ ________
St./Route
City
State
Zip
Co.
❐
.
7
Female
8. Date of Birth
9. Date of Termination
❐
Male
___________________
____________________________
10. Date of initial eligibility for Medicaid for most recent application ______________________
Mo./Year
11. Remarks:
Signature________________________________
Date________________________
Phone_____________________________
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Part II. SSA Completes
1.
Eff. Date of Medicare Part B entitlement_______________________
2. Date claim cleared_________________________
3.
Remarks:
Signature___________________________________________________
Date______________________________
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Part III. Contractor Completes
1.
Enrolled Effective______________________________
2. Deleted Effective___________________________
3.
Should appear on __________________________________________Buy-In Register
4.
Remarks:
Signature_____________________________________________________________
Date________________________________
DMA-5004
Rev. 08/13
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