Fillable Form Dma-3701 - North Carolina Dma Budget Management printable pdf download

Print Form

Health Choice Extended Coverage

_____________________________

DMA Budget Management

_____________________________

2501 Mail Service Center

_____________________________

Raleigh, N.C.

27699-2501

Case ID Number: _________________

Date:

Dear Former NC Health Choice Member,

Health Choice insurance coverage ended on ___________for the child/children listed below because of no longer being eligible.

You can purchase extended Health Choice coverage for up to 12 consecutive months by paying a monthly premium directly to

NC Health Choice in the amount of $187.01 per child.

If you want to purchase extended coverage, please check the appropriate box below for each child you want to cover. You must

date, sign and return this letter in the enclosed envelope. When we receive this notice with your selection(s), we will send a bill

for the amount due. After the first bill, you will then be billed monthly.

This will be your only notice. If we do not receive your response regarding interest in enrolling one or more children in

extended coverage within 30 days from the date of this letter, we will not activate enrollment in extended coverage and

your child or children will no longer have Health Choice insurance coverage as of ______________.

Extended coverage purchased will be cancelled when any of the following situations occur:

1. The 12-month continuation period ends.

2. A child obtains other comprehensive health insurance coverage.

3. The monthly premium is not paid within 90 days of the NC Health Choice cancellation date and each subsequent

monthly premium is not paid within 30 days of the date of each invoice.

4. The covered child turns age 19 (coverage will be cancelled effective the first calendar day of the month after the month

in which the child turns 19).

5. The NC Health Choice program no longer provides extended NC Health Choice.

Your response must be received by the Health Choice administrator by the 30

calendar day after the date of this letter

____________. Please contact Deborah Harris at 919-855-4218 if you have any questions concerning your payment. Please

contact your local County Department of Social Services or 919-855-4000 if you have questions about your eligibility for NC

Health Choice extended coverage, NC Health Choice, or Medicaid.

Sincerely,

Barry Brown

DMA Budget Management

____ I wish to purchase extended coverage for up to 12 months by paying the monthly premium of $187.01 for each child I

have checked below:

Child name

_____________________

Child name ______________________________

Child name

Child name _____________________________

Child name

___ ______

Child name _____________________________

SEND NO MONEY NOW – YOU WILL RECEIVE A BILL FOR THE COVERAGE YOU HAVE SELECTED.

Signature: ______________________________________________________ Date: ___________________

Responsible party

DMA-3701 Revised 4/22/2014

Form Dma-3701 - North Carolina Dma Budget Management

Related Articles

Related forms

Related Categories