NC DHHS 3405 2017 free printable template
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1. Last NameFirst NameMI2. Patient Number 3. Date of Birth(MM/DD/YYY)MonthDayYear 1. American Indian/Alaska Native 2. Asian 3. Black/African American 4. Native Hawaiian/ Other Panic Islander 5. White
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How to fill out NC DHHS 3405
01
Gather personal information: Name, address, date of birth, and Social Security number.
02
Fill out the applicant information section accurately.
03
Provide details about household members, including their names and relationships.
04
Include income information for all household members: earnings, benefits, and any other sources.
05
Specify medical conditions or disabilities, if applicable.
06
Review the completed form for accuracy.
07
Sign and date the application.
Who needs NC DHHS 3405?
01
Individuals or families seeking assistance from North Carolina's Department of Health and Human Services.
02
People applying for Medicaid, food assistance, or other social services in North Carolina.
03
Anyone needing to report changes in their circumstances related to assistance programs.
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What is NC DHHS 3405?
NC DHHS 3405 is a form used by the North Carolina Department of Health and Human Services to report specific health and service data for certain programs or services.
Who is required to file NC DHHS 3405?
Organizations and providers that participate in state-funded health programs or services may be required to file NC DHHS 3405.
How to fill out NC DHHS 3405?
To fill out NC DHHS 3405, follow the instructions provided on the form, ensuring all required fields are completed accurately with relevant data.
What is the purpose of NC DHHS 3405?
The purpose of NC DHHS 3405 is to collect data for accountability and monitoring of health services provided under state programs.
What information must be reported on NC DHHS 3405?
Information that must be reported on NC DHHS 3405 includes service utilization data, patient demographics, and outcomes relevant to the services provided.
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