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NC Department of Health and Human Services
NC Division of
Medical Assistance

Medicaid and Health Choice Applications

For a fast and simple way to apply for Medicaid/NCHC, you may apply online at ePASS.  ePASS is a secure; web-based self-service tool that allows you to submit a Medicaid/NCHC application online as well as apply for other programs such as Food and Nutritional Services. It provides easy-to-use instructions that will guide you through the process.  It also allows you to do a pre-assessment to determine if you are potentially eligible for medical assistance.

You may also mail or bring the completed Medicaid Application to the County Department of Social Services (DSS) in the county where you live. This will begin the application process. Additional forms will be required to be completed after the county evaluates your initial application for Medicaid. 

Note: The free Adobe Acrobat Reader is required to view and print these PDF files.

Program Applications
Application for Health Coverage & Help Paying Costs DMA-5200
Application for Health Coverage & Help Paying Costs (Short Form) DMA-5201
Health Coverage from Jobs - Appendix A DMA-5202-A
American Indian or Alaska Native Family Member (AI/AN) - Appendix B DMA-5202-B
Designation of Authorized Representative - Appendix C DMA-5202-C
Appendix D - Discontinued XXXXXXXX
Medical Bills - Appendix E DMA-5202-E
Income/Resources - Appendix F DMA-5202-F

Aplicacións en Espanol

Programa Aplicación
Solicitud Para Cobertura de Salud y Ayuda Para Pagar los Costos DMA-5200
Apéndice A - Coberta de salud de empleos DMA-5202-A
Apéndice B - Miembro de la familia amerindio o nativo de Alaska (AI/AN) DMA-5202-B
Apéndice C - Designación de representante autorizado DMA-5202-C
Apéndice D - Discontinuado XXXXXXXX
Apéndice E - Facturas médicas DMA-5202-E
Apéndice F - Ingresos/Recursos DMA-5202-F

For more information, see: Ready NC Connect NC