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DMA ADMINISTRATIVE LETTER NO: 04-16, OBSOLETE FORMS

DATE:

May 31, 2016

SUBJECT:

OBSOLETE FORMS

DISTRIBUTION:

COUNTY DIRECTORS OF SOCIAL SERVICES

MEDICAID STAFF

I. BACKGROUND

Form Number

Form Name

DMA-2041

Third Party and Accident Resources Information

DMA-5007

MAABD Redetermination Document

DMA-5007-ia

Medical Assistance to the Aged, Blind, and Disabled Redetermination Document

DMA-5007mr

MA Redetermination Mail In

DMA-5007mr-ia

Medical Assistance – Redetermination Mail in

DMA-5007v

Verification Form for MAABD Mail-In Redetermination

DMA-5007v-ia

Verification Form For MAABD Mail in Redeterminations

DMA-5008d

Transfer from SA to MA

DMA-5008ia

Verification /Eligibility Determination for Medical Assistance Applications ABD

DMA-5015

ABD Mail-In Application Verification Checklist

DMA-5015-ia

Adult Mail-In Application Verification Checklist

DMA-5018

Designation of Authorized Representative

DMA-5030

Reserve History Sheet

DMA-5030A

Reserve History Sheet

DMA-5030-ia

Reserve History Sheet

DMA-5061

Rights and Responsibilities for Qualifying Individuals

DMA-5064

MIC/NCHC Budget Worksheet

DMA-5064-ia

MIC/NCHC Health Choice Budget Worksheet

DMA-5065

MAF Application (Supplement 2)

DMA-5065-ia

M-AF Application – (Supplement 2)

DMA-5065sp

Solicitud M-AF Suplemento 2

DMA-5075

Verification Checklist for MIC/NCHC Reenrollment

DMA-5077

Important Notice About Reenrolling for Medicaid

DMA-5077sp

Lea Este Importante Aviso para la Renovacion de Medicaid

DMA-5080

Mail-In Review for Help with Medicare Costs

DMA-5080-ia

Mail-In Review for Help With Medicare Costs

DMA-5117

Protected Status Tracking Sheet

DMA-5126

Children Health Insurance Status Notification

DMA-5137

Ex Parte Verification of Pregnancy

DMA-5137sp

Ex Parte Verification of Pregnancy (Spanish)

DMA-5138

Ex Parte Review Checklist (Non MIC/NCHC Reenrollment

DMA-5139

Second Party Review Plan for Evaluating Denied/Terminated WFFA Cases for Medicaid

DMA-5140

Second Party Review Sheet

DMA-5162

Transfer of Assets Dates Documentation

DMA-5163

Notice of Opportunity to Provide Medical Costs

DMA-5174

Age Verification

DMA-5177

Documentation of Identity and Citizenship for US Citizens

If you have any questions regarding this information, please contact the Operational Support Team at ost.policy.questions@dhhs.nc.gov.

Dave Richard

Deputy Secretary for Medical Assistance

(This material was researched and written by Natasha Moss, Policy Consultant, Beneficiary Services.)

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  For questions or clarification on any of the policy contained in these manuals, please contact your local county office.


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