Forms for NC Health Choice for Children
Use the forms below to read more about NC Health Choice for Children, apply for enrollment, or submit information about your child requested by the program.
Medical Claim Form
Use this form to request reimbursement for health care services, such as a visit to a doctor not in the provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges.
Appeal a Decision Form
Use this form to appeal a decision or request a grievance review.
Authorize a Representative
Use this form to authorize someone else to access your Protected Health Information.
NC Health Choice for Children Information and Application (English) (PDF, 57KB)Use this document to learn more about the NC Health Choice program and apply for coverage.
NC Health Choice for Children Information and Application (Spanish) (PDF, 57KB)
Applica para la programa NC Health Choice.
NC Health Choice for Children Request for Visual Aids and Eligibility Verification (PDF, 267KB)
Providers must use this form to request visual aids and to verify eligibility of chiildren in the NC Health Choice program. Fax completed forms to (252) 459-7400.
Information For Speech-Language Pathologists Regarding North Carolina
Health Choice Members, Including Children With Special Needs (PDF, 21KB)
This document describes resources and guidelines for speech-language pathologists to request service authorization for children in the NC Health Choice program, especially children with special needs.
Health Choice Special Needs Clinical Review Summary
This form requests clinical details regarding a child’s communication skills. Use it when applying for Speech Therapy coverage for children with special needs. The form is available in two formats. Choose the one format that best suits your needs.
- Excel (21 KB)
On a computer, type the requested information into the form. Print the completed form before submitting it.
- PDF (20 KB)
Print the form first. Then handwrite the requested information on the form before submitting it.
The State Health Plan uses this form to request medical records from a speech therapist. Use it when applying for Speech Therapy coverage.
Physician Certification: Children with Special Health Care Needs (PDF, 20KB)
Children with special health care needs may be eligible for benefits above the core services in the NC Health Choice Program. In order for these services to be reimbursed, providers must document eligibility criteria using this form.
