North Carolina Department of Health and Human Services Division of Health Benefits
Health Insurance Information Referral Form
This form is designed to give the Medicaid program information that can be used to verify or reverify private health insurance coverage for Medicaid recipients.

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Recipient Last Name is required.

Recipient First Name is required.

Medicaid ID# is required.

Enter a valid 10 digit alphanumeric Medicaid ID.

 

Enter a valid SSN.

 
 

Insurance Company Name is required.

 
 

Policy Number is required.

 

Enter a valid Policy Begin Date (MM/DD/YYYY).

Policy Begin Date is required.

Enter a valid Policy Begin Date (MM/DD/YYYY).

Policy End Date is required.

 
 

Insured's Last Name is required.

Insured's First Name is required.

 
 
 
 
 

Enter a valid Zip Code (XXXXX or XXXXX-XXXX).

 
 

Contact Email is required.

Enter a valid Contact Email.

 
  Insurance documentation gives information that should be used to update Medicaid's files, such as the following:
 
 

Please enter valid date (MM/DD/YYYY).

 

Please enter valid date (MM/DD/YYYY).

 
 
Enter the text shown below in to the box provided before clicking Submit.

Captcha

Please enter correct catchphrase.


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