Dma 2057 Form – Fill Out and Use This PDF

Division of Medical Assistance

Health Insurance Information Referral Form

Recipient Name: _______________________________________________________________________

Recipient ID No: _______________________________		Date of Birth: ___________________________
Health Ins. Co. Name (1)	________________________	Policy/Cert No.__________________________
(2)	________________________	Policy/Cert No.__________________________

	Reason For Referral
1._____	Recipient never covered by or added to above policy(s) (EOB attached)
2._____	Recipient’s insurance coverage terminated (EOB attached)

3._____ New policy not indicated on Medicaid ID card (EOB or copy of insurance card attached) Indicate type coverage:

(Do not include Medicare)
_____	Major Medical	______	Hosp/Surgical	_____	Basic Hospital
_____	Dental	______	Cancer	_____	Accident
_____	Indemnity	______	Nursing Home

Attach original claim, a copy of the EOB or a copy of the insurance card and submit to: DMA - TPR, 2508 Mail Service Center, Raleigh, North Carolina 27699-2508. The Third Party Recovery (TPR) Section will update the system and forward claims to EDS within 10 working days after receipt.

Provider Name:__________________________ Provider Number: _______________________________

Submitted By:___________________________ Date Submitted: ________________________________

Telephone Number:

DMA 2057

Revised January 2003