Health Insurance Referral Form

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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* Indicates required field.

* Recipient Last Name:		* Recipient First Name:
Recipient Last Name is required.		Recipient First Name is required.
Recipient Date of Birth:
Enter a valid Recipient Date of Birth (MM/DD/YYYY).
* Medicaid ID#:
Medicaid ID# is required. Enter a valid 10 digit alphanumeric Medicaid ID.
SSN:
Enter a valid SSN.
* Insurance Company Name:
Insurance Company Name is required.
* Policy Number:
Policy Number is required.
Policy Begin Date:		Policy End Date:
Enter a valid Policy Begin Date (MM/DD/YYYY).		Enter a valid Policy End Date (MM/DD/YYYY).
Group Number:

* Insured's Last Name:		* Insured's First Name:
Insured's Last Name is required.		Insured's First Name is required.
Employer's Name:

Employer's Address 1:		Employer's Address 2:

City:		State:

Zip Code:
Enter a valid Zip Code (XXXXX or XXXXX-XXXX).
Submitter First Name:		Submitter Last Name:

Contact Phone:		* Contact Email:
		Contact Email is required. Enter a valid Contact Email.

* REASON FOR REFERRAL: (PLEASE SUPPLY AS MUCH INFORMATION AS POSSIBLE)

	The recipient's Medicaid eligibility file does not list the policy above.
	Insurance documentation gives information that should be used to update Medicaid's files, such as the following:
	Recipient has never been covered by the policy.
	Recipient's coverage ended (date) Please enter valid date (MM/DD/YYYY).
	Policy lapsed (date) Please enter valid date (MM/DD/YYYY).
	Carrier has changed; new carrier is
	Other

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

Please enter correct catchphrase.

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