Dma 9006-2026

1. Click ‘Get Form’ to open the dma 9006 in the editor.
2. Begin by filling in the 'Case #' and 'Dist. #' at the top of the form. Ensure these numbers are accurate as they are essential for identification.
3. Enter the date, county, and fax number in their respective fields. This information is crucial for processing your enrollment.
4. Complete the section labeled 'Person Completing Form' with your name, followed by details of the case head including their name and MID.
5. Fill out the preferred language, address, telephone number, cell number, and email address to ensure proper communication.
6. List individuals to be enrolled along with their date of birth and primary care provider information in the designated fields.
7. If requesting a temporary exemption, provide detailed reasons in the space provided and attach additional paper if necessary.
8. Finally, ensure that you or a guardian signs and dates the form at the bottom to certify receipt of information regarding CCNC/CA.

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