Completing the DMA 5097 form is a crucial step for individuals seeking to apply for or re-enroll in Medicaid or Special Assistance programs. This comprehensive form requests a variety of information, ranging from personal identification details such as the applicant's name and contact information to more specific data like medical bills, proof of income, bank statements, and documentation related to one's health insurance. The aim of gathering this information is to ensure that applicants meet the eligibility criteria for the benefits they're applying for. Importantly, the form acknowledges potential challenges in obtaining some of the requested documents by offering alternatives or the option to contact a caseworker for assistance. Furthermore, it provides a deadline by which the information should be submitted to avoid delays in processing applications, along with options for those who might need additional time or help in compiling the necessary documentation. This form serves as a bridge between applicants and the assistance they need, emphasizing the importance of clear communication and prompt action from both parties.
| Question | Answer |
|---|---|
| Form Name | Dma 5097 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | dma 5097, dma 5097 rev 06 11, medicaid 5097 form, dma 5097form |
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Request for Information |
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To: |
________________________________________________ |
County Case No. |
_____________________________________ |
Address: ________________________________________________ |
District No. |
_____________________________________ |
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________________________________________________ |
Worker’s Name |
_____________________________________ |
Date: |
________________________________________________ |
Telephone Number ____________________________________ |
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We need additional information to process your Medicaid/Special Assistance
by________________________ to ensure that your
If you cannot get the items checked below, there are other items we can use. Continue reading for other items we can accept.
1. Medical bills from_____________________________________________________________to present and any old unpaid medical bills.
2. Medical verification of pregnancy___________________________________________________________________________________
3.
4. Proof of income for ______________________________________for the month(s) of _________________________________________
5. Proof of
income tax return for the year_______________________________________________________________________________________
6. Bank account numbers or statement(s) showing balance for the months of ___________________________________________________
7. Bank Consent form/Release of Information forms signed by _______________________________________________________________
8. Life insurance policies or the name of the insurance companies and policy numbers for__________________________________________
9. Proof of beneficiary of the annuity____________________________________________________________________________________
10. Proof that North Carolina Medicaid Program is named as a Remainder Beneficiary for an annuity__________________________________
11. Name and contact information for issuer of an annuity____________________________________________________________________
12. Social Security Number for _________________________________________________________________________________________
13. Documentation of alien status for ____________________________________________________________________________________
14. Apply for Unemployment Benefits for__________________________________________________________________________________
15. Apply for Social Security Disability for_________________________________________________________________________________
16.
17. Health Insurance card or the name of the company and policy number________________________________________________________
18. Proof of Citizenship and Identity for___________________________________________________________________________________
__________________________________________________________________________________________________________________
19. Proof of State Residence for ________________________________________________________________________________________
20. Proof of homesite equity____________________________________________________________________________________________
21. Documentation to rebut a transfer of assets sanction or to prove a transfer of assets sanction will cause an undue hardship or both.
(See attachment) _________________________________________________________________________________________________
22. Other__________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Do you need help or more time to get the information to complete your
1.Call your Medicaid caseworker_________________________________________ at ______________________________________________
OR
2.Sign and return the bottom portion of this form to DSS.
I need help getting the information to complete my application /
I need more time to get the information.
Applicant’s Name______________________________________ Telephone Number________________________________________________
Address_____________________________________________________________________________________________________________
OTHER ITEMS WE CAN ACCEPT TO PROCESS YOUR MEDICAID
If you are unable to get the items checked or the items described below, please contact your caseworker immediately. Your caseworker will help you.
MEDICAL BILLS
If you do not have all of your medical bills, you can provide:
1.Receipts from medical providers.
2.Statements from medical providers.
3.Cancelled checks to medical providers.
4.Names, addresses, phone numbers of medical providers.
5.Private health insurance receipts, premium books, name of agent.
6.“Explanation of Benefits” letters (EOB) from Medicare and/or private health insurance.
7.To show proof of
8.To show proof of medical transportation costs, provide a receipt or statement from the person if someone else took you to the doctor, drug store, or other medical facility.
WAGES
If you don’t have wage stubs provide one of the following:
1.A statement or form completed by your employer.
2.Personal business records for
PROOF OF OTHER INCOME
Such as Veteran’s benefits, Railroad Retirement, other retirement income, rental income, farm income
1.Copy of check.
2.Award letter or other document from the source of income.
3.A statement from the source of the income or from person in charge of dispensing income(trust funds, etc).
4.Records of payment received from roomers/boarders.
5.Records from the person paying you room/board.
6.Tax records.
7.Records of farm income.
8.Landlord’s records of rental income.
9.Records of
10.A signed statement from your bank, real estate agent, or person renting from you stating how much money you get.
PROOF OF CHILD CARE OR ADULT CARE
If you are applying for certain Family and Children’s Medicaid programs there is a $200 per month limit for child care for a child under age two and $175 per month limit for care for a child age two or older and for an adult. You can provide:
1.Statement or receipt from person or the facility providing care. Statement or form indicating whether you are charged a flat fee or an hourly rate.
2.Your record of payment made for child or adult who is your dependent.
PROOF OF OPERATIONAL EXPENSES
If you don’t have receipts to prove expenses for rental property or
1.Personal records of expenses such as ledger sheets, check stubs, or tax records.
2.Associations, ASCS Office, and purchase of farm products.
3.Written statements from people who sell you supplies.
4.Written statements from people who provide you with services so that you can earn money.
5.Written statement from real estate agent.
HEALTH INSURANCE
If you don’t have your health insurance card, you may provide the name of the insurance company and the policy number.
REVISED 06/08