Get the free nc dma cocr form - ncdhhs

County Options Change Request Form COCR Send this Form to DMA Health Check Consultant Managed Care/Division of Medical Assistance 2501 Mail Service Center Unit 16 Raleigh NC 27699-2501 Courier 56-20-06 Fax 919 715-0844 or 919 715-5235 Date Please Print Network Name Network Medicaid Provider Number Supervisor Signature Phone DMA Approver DMA Approval Date Change Health Check Coordinator Information List the Health Check Coordinator name and cont...

How to fill out nc dma cocr form

How to fill out the NC DMA COCR form:

1. Gather all necessary information and documents such as your personal information, income details, health insurance information, and any supporting documentation required.
2. Download or obtain a physical copy of the NC DMA COCR form from the official website of the North Carolina Department of Medical Assistance (DMA).
3. Carefully read the instructions provided with the form to understand the requirements and sections to be filled.
4. Begin filling out the form by entering your personal information accurately, including your name, address, contact details, and social security number.
5. Provide information regarding your income, including details about your job, employer, wages, and any other sources of income.
6. If you have health insurance, provide the relevant details such as the name of your insurance provider and policy number.
7. Complete the remaining sections of the form, ensuring you double-check all the information you have entered for accuracy and completeness.
8. If any additional documentation is required, make sure to attach all the necessary supporting documents to the completed form.
9. Once you have completed the form and attached any required documents, review everything one final time to ensure accuracy and completeness.
10. Sign and date the form where indicated.
11. Submit the form either by mailing it to the address provided on the form or by delivering it in person to the designated office.

Who needs the NC DMA COCR form:

1. Individuals who are applying for or seeking to renew their eligibility for medical assistance or Medicaid in the state of North Carolina.
2. Anyone who wants to determine if they meet the income and eligibility requirements for health coverage programs offered by the North Carolina Department of Medical Assistance.
3. Residents of North Carolina who need to provide updated information or report changes in their circumstances to the Department of Medical Assistance.

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What is nc dma cocr form?

NC DMA COCR form stands for North Carolina Department of Medical Assistance Coordination Change of Ownership and Control Interest form. It is a form used to notify the North Carolina Division of Medical Assistance of any changes in ownership or control of a healthcare provider.

Who is required to file nc dma cocr form?

Any healthcare provider in North Carolina that undergoes a change in ownership or control is required to file the NC DMA COCR form.

How to fill out nc dma cocr form?

To fill out the NC DMA COCR form, you will need to provide information such as the provider's name, Tax ID number, Medicaid Provider ID, details of the change in ownership or control, and any other requested information. The form can be downloaded from the North Carolina Division of Medical Assistance website.

What is the purpose of nc dma cocr form?

The purpose of the NC DMA COCR form is to ensure that the North Carolina Division of Medical Assistance is informed of any changes in ownership or control of healthcare providers, which may impact the provider's eligibility to participate in Medicaid programs.

What information must be reported on nc dma cocr form?

The NC DMA COCR form requires reporting of the provider's name, Tax ID number, Medicaid Provider ID, type of change in ownership or control, effective date of the change, and any additional requested information.