DHHS 3014/3056 Authorization Request/ (M M/DD/YYYY ... - epi publichealth nc-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Last Name, First Name, and Middle Initial in the designated fields.
3. Input your Current POMCS/ADAP Case Number if you are a returning client; leave it blank if you are a new applicant.
4. Fill in your Social Security Number and Date of Birth (MM/DD/YYYY) as required.
5. Select the Program from the options provided, ensuring you choose 'N.C. Department of Health and Human Services'.
6. Complete the Diagnosis Code field with the appropriate code (e.g., B20).
7. Indicate your Application Type by checking the relevant box for New Application or Renewal, and provide Requested Dates of Service if applicable.
8. Fill out your address details accurately, ensuring they match any documentation of residence.
9. Continue filling out demographic information such as Gender, Race, Ethnicity, and Language preferences.
10. Provide financial information including Countable Family Members and Income details as instructed on the form.

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