PROVIDER RELATIONS FORMS

Provider Enrollment Applications

  • NC Medicaid Provider Enrollment Application
  • NC Medicaid Provider Enrollment - CIS Addendum to Add Services
  • NC Medicaid Provider Enrollment for CAP Services - CAP Addendum to Add Services
  • NC Medicaid Provider Enrollment for CABHA
  • Provider Direct Enrollment Application
  • Provider Change in Status Form
  • Provider Physical Location Form
  • Performing Provider Profile
  • Provider Endorsement
  • Provider Monitoring

  • Provider Technical Assistance Form
  • Provider Quarterly Incidents Report - QM11
  • Incident Response and Improvement System

  • QM11 Provider Quarterly Incident Report rev 10/10
  • QM04 DHHS Restrictive Intervention Detail 11/04
  • Incident and Death Response System Manual 11/04
  • IRIS Technical Manual 6/10
  • Service Management – SOC Forms

  • SOC CTSP Program Referral Form
  • SOC Child-Family Team Meeting Referral Form
  • SOC CTSP Request for Community Development Form
  • Provider Community Intervention Services (CIS)/Enhanced Benefits Application/NC Medicaid Enrollment Application
  • CAP-MR/DD Waiver Services Application
  • CAP-MR/DD Waiver Services Addendum
  • Packet Technical Assistance Form
  • CAP-MR/DD Information

  • Overview of CAP
  • Waivers
  • Manual for the f2008 CAP-MR/DD Comprehensive Waiver
  • Manual for the 2008 CAP-MR/DD Supports Waiver
  • Manual Revisions (Released 7/22/10)
  • Risk Issue Identify Tool
  • Risk Identification Tool Instructions
  • Cost Summaries – Comprehensive
  • Cost Summaries – Support
  • Provider Billing Information

  • Provider Checkwrite Schedule for Period 07/10 – 12/11
  • CareLink Procedure Code Billing Instructions
  • Array of Services - 1011 - Master 5-16-11
  • Client Billing Information Form
  • Provider Billing Requirements Procedure
  • Form Instructions Client Billing Information
  • Instructions for Completing Service Authorization Request Form
  • Monthly Collection Report Form
  • Out of Home Community Placement Form
  • Perform Provider Profile Form
  • Provider Choice Acknowledgement Form
  • Provider Physical Location Form revised 083107
  • Service Authorization Form
  • Demographic Form
  • Discharge Process
  • Termination Request Form
  • Room & Board Letter - Parent Guardian
  • Room & Board Letter - DDS
  • Room & Board Letter - Auth of R&B