Form Dma-5020 - North Carolina Division Of Medical Assistance Notice Of Case Status
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2(Provider completes)
North Carolina Division of Medical Assistance
Notice of Case Status
Enter Name and Address of County DSS
NOTE:
DO NOT make this referral
without the knowledge or consent
_________________________________________________________________
of the patient and/or his family.
_________________________________________________________________
_________________________________________________________________
Please determine whether the patient is eligible for medical assistance under Title XIX Medicaid. Use the reverse side to notify
us of your decision.
1.
Patient’s Name (First, Mi, Last)
2. Telephone number
3. Address
4. Date of Birth
5. Social Security Number
6. Sex
Female
Male
7. Spouse’s Name
8.
Parent’s/Guardian’s Name (Give only if patient is a minor child)
9.
Inpatient Hospital Admission Date:
_____________________Month _______________ Day 20______________Year
10. Estimated Discharge Date:
____________________Month ________________ Day 20 ______________Year
11. Daily Charges-to-Date:
____________________Attached _________________ Will be provided upon discharge.
_____________________________________________
________________________________
_______________________________
Name of person completing form
Date
Title
Provider’s Name and Address
Telephone Number
Consent of Patient/Parent/Guardian to referral
______________________________________________
_______________________________ _______________________________
Signature
Date
Relationship to Patient
Instructions
1. Provider:
a. Do not make this referral without the knowledge or consent of the patient and/or his family.
b. Prepare original and one copy. Send original to the county DSS and retain the copy for your files.
2. County:
See reverse side of this form for detailed instructions.
DMA-5020
Revised 01-04
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