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Forms

Access key forms for contracts, agreements, authorizations, and more.

Physician/Allied Contract Packet

If you provide services such as primary care, specialist care, mental health, substance abuse and more, please download and complete the forms below:

North Carolina Medicaid Cover Letter

North Carolina Medicaid Instructions Guide

North Carolina Medicaid Participating Provider Agreement

North Carolina Medicaid Provider Profile Sheet

W-9 Form

Ancillary Contract Packet

If you provide services such as home health, Personal care services, hospice, DME, Inpatient services and more, please download and complete the forms below:

North Carolina Medicaid Cover Letter

North Carolina Medicaid Instructions Guide

North Carolina Medicaid Ancillary Provider Agreement

North Carolina Medicaid Ancillary Profile Sheet

W-9 Form

Provider Resources

This report is to be completed for ALL injuries occurring within a facility. Report is to be printed and submitted to Risk Management within 24 hours of occurrence. Fax to:

Because WellCare Health Plans denied your request for coverage of (or payment for) a prescription drug, you have the right to an appeal.

LTSS Request for PCS Assessment

YMCA Provider Referral Replacement Form

Please use this form to request coverage of a drug that we would not usually cover or would restrict in some way.

Weight Watchers (WW)/Curves Baseline

Prior Authorization Forms

Authorization approves the medical necessity of the requested service only. It does not guarantee payment, nor does it guarantee that the amount billed will be the amount reimbursed.

Drug Prior Authorization Requests Supplied by the Physician/Facility

Clinical information and supportive documentation should consist of current physician order, notes and recent diagnostics. Notification is required for any date of service change.

Prior Authorization Form

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Last Updated On: 12/13/2020