Forms

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• Agreement for Participation as a Primary Care Provider in North Carolina's Patient Access and Coordinated Care Program (Carolina Access) (103 KB PDF)
• Electronic Claims Submission (ECS) Agreement for Individuals (33 KB PDF)
• Electronic Claims Submission (ECS) Agreement for Organizations (Groups) (79 KB PDF)
• Medicaid Letter of Attestation (54 KB PDF)
• Pharmacy Online request for NC Medicaid claims Point-of-Sale (12 KB PDF)
• Provider Administrative Participation Agreement (105 KB PDF)
• Provider Certification for Signature on File (45 KB PDF)
• Reporting a Change in Provider Status
• W-9: Request for Taxpayer Identification Number and Certification (268 KB PDF)

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