Dma 5028-2025

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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 information from the individual authorizing the disclosure and specifies the purpose of sharing this information, primarily for determining eligibility for benefits. It also includes legal disclaimers regarding privacy and the handling of disclosed information.

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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 for disclosure. This includes medical records and educational evaluations related to your impairments.
Complete the 'FROM WHOM' section by listing all sources from which information will be disclosed, such as hospitals or schools.
Specify the purpose of this authorization in the 'PURPOSE' section, ensuring it aligns with your needs for benefits eligibility.
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.

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 Carolina the largest producer of?

North Carolina is number one nationally in the production of tobacco and sweet potatoes. North Carolina ranks second in the US for hog and turkey production, and Christmas tree sales.

What is North Carolina identity management?

What is NCID? North Carolina Identity Management Service (NCID) was established to control access to secure online resources for many NC government agencies, including the NC Department of Revenue.

What counties are in the Charlotte DMA?

Counties County2022 EstimateArea Catawba County 163,462 401.40 sq mi (1,039.6 km2) Cleveland County 100,670 464.25 sq mi (1,202.4 km2) Burke County 87,881 514.24 sq mi (1,331.9 km2) Caldwell County 80,492 474.61 sq mi (1,229.2 km2)5 more rows

Is NC Medicaid Direct the same as Medicaid?

NC Medicaid Direct is North Carolinas health care program for NC Medicaid beneficiaries who are not enrolled in NC Medicaid Managed Care. It includes care management by Community Care of North Carolina (CCNC), the primary care case management entity for physical health services.

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Key Facts About Form DMA-5028

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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.

Dma 5028-2025

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How to use or fill out dma 5028 with our platform

See more dma 5028 versions

Complete this form in 5 minutes or less

Got questions?

How do I contact Medicaid in North Carolina?

What is North Carolina the largest producer of?

What is North Carolina identity management?

What counties are in the Charlotte DMA?

Is NC Medicaid Direct the same as Medicaid?

Key Facts About Form DMA-5028

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What is North Carolinas DMA?

5028

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