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NC Medicaid-372-124 9.2018 . 16. Discharge Plan: SNF ICF Dom Other: OOS NF OOS Vent CAP/CH Hosp CAP/DA SNF CAP/DA ICF Other: Spec. Hosp Rehab Extended Care Current Level of Care: Other: Requested Level of Care: 1. Recipient Last Name: 2. First Name: 3. Recipient DOB: 4. Recipient ID # 5. Recipient Gender: 6. SSN: 7.
adult care home fl2 form prior approval utilization review on-site review . identification . 1. patient’slast name first middle . 2. birthdate (m/d/y) 3. sex. 4. admission date (current location) 5. county and medicaid number 6. ... 9.2018 nc medicaid 372-124. 21. physician’s signature date . print form . title: dma-327-124-ach-ia.pdf ...
17 Σεπ 2019 · Adult Care Home FL2 Form NC Medicaid 372 124 9 2018. ... PDF • 215.15 KB - September 17, 2019 Contact Information. NC Medicaid, Division of Health Benefits 2501 Mail Service Center Raleigh, NC 27699-2501. NC Medicaid Contact Center Phone: 888-245-0179. Monday-Friday 8 a.m. to 5 p.m.
NC DMA Long Term Care FL2 Form Recipient Information DMA372-124 1. Recipient Last Name:_____ 2. First Name:_____ 3.
Title: dma-327-124-ach-ia.pdf Author: DMA Subject: Adult Care Home FL2 Form Created Date: 8/13/2015 11:33:55 AM
dma-372-124-ach-ia Adult Care Home FL2 Form. Open Preview. File Type: pdf File Size: 213 KB Categories: Health Benefits/NC Medicaid Tags : Form ... 2001 Mail Service Center Raleigh, NC 27699-2000. Customer Service Center: 1-800-662-7030 Visit RelayNC for information about TTY services. Division of Budget and Analysis. 2001 Mail Service Center ...
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