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Dma 5118-2026
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- Click ‘Get Form’ to open the dma 5118 in the editor.
- Begin by entering the Medicaid recipient’s name and ID number in the designated fields. This information is crucial for identifying the individual receiving services.
- Next, input the date of service in the provided space. Ensure that this date corresponds with when the Medicaid-covered service was rendered.
- Fill in the name of the Medicaid provider or facility where the service was provided. This helps verify that the service was conducted by an authorized provider.
- Instruct users to print their name clearly in the section for the individual completing the form, followed by their phone number for any necessary follow-up.
- Finally, ensure that you sign and date the form at the bottom to validate its authenticity before submission.
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DHB-5118A-ia Medicaid Transportation Verification of Receipt of Covered Service A NC Department of Health and Human Services 2001 Mail Service CenterRead more
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