Enrollment Form For Medicaid Recipients printable pdf download

Enrollment Form For Medicaid Recipients

Community Care of North Carolina/Carolina ACCESS

Enrollment Form for Medicaid Recipients

This form must be completed by a staff member with your practice on behalf of the recipient.

PRACTICE INFORMATION:

Date: _______________County: __________________

Staff completing form: ___________________________________________________________

Name of Practice: ______________________________________________________________

Carolina ACCESS Medicaid ID Enrollment Number: ____________________________________

PATIENT INFORMATION:

Head of Household: _____________________________ Preferred Language: _____________

Address: ______________________________________________________________________

Street

_____________________________________________________________________________

City

State

Zip Code

Telephone # ________________ Cell # ________________Email: ________________________

Person to be Enrolled

Date of Birth

MID

 Transportation to doctor needed

 Referred for county transportation

 Handbook provided at time of interview  Handbook mailed to head of household

SIGNATURE OF PATIENT OR HEAD OF HOUSEHOLD IF PATIENT IS A MINOR:

______________________________________________ DATE: __________________

(By signing, I certify that I have received an explanation of the benefits of Carolina

ACCESS and my freedom to choose a participating provider,

(If I have Medicare, I have read the Fact Sheet “Your Health Care—If you Have Medicare

Already, this will help you” and the insert to the Handbook “Community Care of North

Carolina—A Member Handbook”)

Mail or fax the completed form to the department of social services in the county in which

the recipient resides

Division of Medical Assistance

Community Care of North Carolina/Access Care

Revised 1/10/11

Enrollment Form For Medicaid Recipients