Local Management Entities - NC Medicaid 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and other personal identifying information in the designated field. This is crucial for ensuring that your consent is accurately linked to your records.
3. Next, review the list of information categories provided. Initial each category that applies to you, such as assessment details, treatment recommendations, and attendance records.
4. In the purpose section, clearly state why you are allowing this information to be disclosed. This helps clarify the intent behind sharing your data with the county department.
5. Sign and date the form at the bottom. Ensure that a witness also signs if required, as this adds an extra layer of validation to your consent.
6. Finally, confirm whether you received a copy of this consent form for your records by circling 'Yes' or 'No' and providing a reason if applicable.

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