NC MEDICAID PROVIDER REGISTRATION FORM

COMMUNICATION ACCESS AUXILIARY AIDS AND SERVICES REIMBURSEMENT

Please complete this form to register for the NC Medicaid Communication Access Pilot initiative. Once registered, you will be able to be reimbursed for communication access services for Deaf, Hard of Hearing, and DeafBlind Medicaid/Health Choice beneficiaries and their companions. For questions please contact the NC Division of Services for the Deaf and Hard of Hearing at DSDHH.Medicaid.CommAccess@dhhs.nc.gov.

Question Title

PROVIDER INFORMATION (Required.)

Office/Agency Name *

Office/Agency NPI *

Address *

Address 2

City/Town *

State *

Zip Code *

County *

Question Title

PRIMARY CONTACT PERSON (Required.)

Name

Email Address

Phone Number

Fax Number

When submitting reimbursements, DSDHH will need to collect the name of the healthcare provider who performed the service and their NPI number.

Question Title

How many healthcare providers does your office/agency have? (Required.)

Less than 5

5 - 10

11 - 20

More than 20

Question Title

Has your office/agency ever worked with Deaf, DeafBlind, Hard of Hearing individuals in the past? (Required.)

Yes

NC MEDICAID PROVIDER REGISTRATION FORM

COMMUNICATION ACCESS AUXILIARY AIDS AND SERVICES REIMBURSEMENT

Question Title

* PROVIDER INFORMATION (Required.)

Question Title

* PRIMARY CONTACT PERSON (Required.)

Question Title

* How many healthcare providers does your office/agency have? (Required.)

Question Title

* Has your office/agency ever worked with Deaf, DeafBlind, Hard of Hearing individuals in the past? (Required.)

PROVIDER INFORMATION (Required.)

PRIMARY CONTACT PERSON (Required.)

How many healthcare providers does your office/agency have? (Required.)

Has your office/agency ever worked with Deaf, DeafBlind, Hard of Hearing individuals in the past? (Required.)