Dma 5028-2026

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The document is a Form DMA-5028 from the North Carolina Division of Medical Assistance, which serves as an authorization for individuals to disclose their medical and educational records. It outlines the types of information that can be shared, including details about mental health, substance abuse, and educational evaluations. The form requires personal identification details and specifies the purpose of disclosure related to determining eligibility for benefits. It also includes information on the rights of individuals regarding their data and the legal framework governing such disclosures.

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Click ‘Get Form’ to open the dma 5028 in the editor.
Begin by filling in your personal information at the top of the form. Enter your first name, middle name, last name, and birthday in the specified format (mm/dd/yy).
Next, provide your Social Security Number (SSN) and address. Ensure that all details are accurate to avoid processing delays.
In the 'Authorization to Disclose Information' section, clearly indicate what records you authorize to be disclosed. This includes medical records and educational evaluations related to your impairments.
Specify from whom the information will be obtained by listing relevant sources such as hospitals, schools, or social workers.
Indicate the purpose of this disclosure and note that this authorization is valid for 12 months from the date signed.
Finally, sign and date the form at the bottom. If applicable, have a witness sign as well.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (75 Votes)
2015	4.8 Satisfied (40 Votes)
2003	4.4 Satisfied (121 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the monthly income limit for Medicaid in NC?

North Carolinas Transformation to NC Medicaid Managed Care On July 1, 2021, most Medicaid beneficiaries began receiving the same Medicaid services under NC Medicaid Managed Care. With managed care, beneficiaries choose a health plan and get care through the health plans network of doctors.

How do I contact NC Medicaid customer service?

Call us toll free at 1-833-870-5500 (TTY: 711 or RelayNC.com).

What is NC Medicaid called now?

Log into your states Medicaid portal Many states have online portals where you can check your Medicaid coverage status. If you already created an account when you applied, log in to see any updates or changes to your status. Look for a section that shows your coverage details or current eligibility.

How do I contact Medicaid in North Carolina?

To find yours, use this directory or call the NC Medicaid Contact Center at 1-888-245-0179. Walk-ins are available at all local offices. You can also call to schedule an in-person or phone interview (recommended).

What is North Carolinas DMA?

The North Carolina Division of Medical Assistance (DMA) manages the Medicaid and Health Choice programs. Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities.

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