Health Check Application

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HEALTH CHECK (MEDICAID)
NC HEALTH CHOICE FOR CHILDREN APPLICATION
Free or Low-Cost Health Coverage
This application may also be used by parents, caretakers, pregnant women & other adults to apply for Medicaid.
Si usted desea obtener la forma DMA-5063, solicitud en español para seguro medico para niños,
comuníquese con el departamento de servicios sociales de su localidad. También puede llamar al Centro de
Atención al Cliente del Departamento de Salud y Servicios Humanos (DHHS, por sus siglas en inglés) al
1-800-662-7030. Se le atenderá en español. (You can get a Spanish application at your local department of
social services or call 1-800-662-7030.)
WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN?
Health Check (Medicaid) and Health Choice are two similar health coverage programs. Your family’s
income, the number of people in your family and the age of the children determine if you or your children
qualify. This information will also be used to determine in which program the children will be enrolled.
WHAT ARE THE BENEFITS?
Sick visits
Counseling
Eye exams and glasses
Checkups
Prescriptions
Hearing exams and hearing aids
Hospital care
Dental Care
And more!
Transportation - Medical transportation may be available to individuals authorized and receiving Health Check
(Medicaid). If you need assistance with transportation to receive medical care, contact your local department
of social services after you receive a letter approving Health Check (Medicaid). If the children are enrolled in
Health Choice, you must provide your own transportation.
HOW DO I APPLY?
It's easy. Just mail or drop off the completed application at the department of social services in the
county where you live. If you would like help filling out the application, call or visit your department of social
services. You can find the address and phone number in your phone book under “County Government” or by
calling the DHHS Customer Service Center at 1-800-662-7030.
Be careful to answer all the questions completely so we can process your application more quickly.
If you need more space, please attach additional pages. It can take 45 days or less to process your
application. If we need additional information, we will contact you by mail. The sooner we get the
information, the sooner we can let you know if you or your children qualify.
WHO CAN ANSWER MY QUESTIONS?
Contact the department of social services in the county where you live or call the DHHS Customer Service
Center at 1-800-662-7030.
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
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