DMA-5118B-ia.pdf. Medicaid Transportation Verification of Receipt of Covered Service- B - info dhhs state nc 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Medicaid recipient’s name and ID number in the designated fields.
3. Fill in the date when the service was received, ensuring accuracy for audit purposes.
4. Provide the name of the Medicaid provider or facility where the service was rendered.
5. Complete the section with your name, title, and phone number as the individual completing this form.
6. Sign and date the form to certify that all information is correct.
7. In the consent section, have the Medicaid beneficiary or their representative sign and date to authorize information release.

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