Nc Provider 2057 Referral Form PDF Details

The NC Provider 2057 Referral form plays an essential role in the healthcare system, particularly for those involved in administering or updating Medicaid recipient information. It is designed to streamline the process of submitting changes to said information, ensuring that requests are dealt with efficiently, within a 48-hour window. This specific form requires various pieces of critical information, including the recipient's Medicaid ID number, first and last name, and details about their insurance company, such as the name and policy ID. Additionally, it allows for comments to be added, providing space for any necessary remarks or explanations. From the provider's end, contact details including their first and last name, the name of their practice or institution, their phone number, and email address must be filled out. This comprehensive approach not only facilitates a smoother communication channel between providers and Medicaid but also underscores the importance of accuracy and promptness in handling recipient information. With fields marked to indicate required information, it ensures that all submissions are complete, thereby supporting the Program Integrity efforts of the DMA.

QuestionAnswer
Form NameNc Provider 2057 Referral Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshms2507referralform, hms referral form 2057, hms nc referral form, hms 2057

Form Preview Example

NC PROVIDER 2057 REFERRAL FORM

Please use this form to submit changes to recipient information. All requests will be completed within 48 business hours.

* Indicates Required Field

 

Recipient Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid ID Number:

 

 

* ex: 900123456L

 

 

 

 

 

Recipient First Name:

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recipient Last Name:

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Company

 

 

 

 

*

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy ID:

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Contact Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Name:

 

 

 

 

 

 

 

 

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Phone Number:

 

(

 

)

 

 

 

-

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Email Address:

 

 

 

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Program Integrity

DMA, 647-8136

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