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Wake North Carolina online Form 5558: What You Should Know

If you are deaf, hard of hearing or have a disability requiring additional resources, please complete and mail the Enrollment forms to: N.C. Medicaid Administration, PO Box 1320, Raleigh, NC 27612, or call: A. Enrollment Information: Complete and email the Enrollment form. We will contact you with your contact information. D. Enrollment Waiver Form: Email the waiver form (downloadable, at for the online or on paper) of your consent to release your state information to your Medicaid agent. E. Enrollment Waiver Application: The application must be completed, signed and notarized. The application must include information on: 1) Current address and telephone number, 2) Number of dependents you have, 3) Name(s) of children under your care that you know are eligible for Medicaid in the state, if not yet enrolled. 4) Information on any previous medical or mental health treatment you have received and, if applicable, any other information required by the state. 5) Current, full and updated health insurance account number. Please note the information provided on your health insurance account, and the details of any coverage, will be added to your online record. 6) Signature and date provided at time of application. You must include a copy of your current and valid driver's license and/or identification card and a valid e-mail address with your enrollment application. If you are younger than 18 years of age, and you have not signed a written consent, please call us and let us know that you would like to enroll under the Children's Health Insurance Program and consent to release your state information to your Medicaid agent. F. Medicaid Waiver Information Form: Please print out and save this form and bring with you to your Medicaid/Medicare office, along with your signed enrollment waiver. G. Medicaid/Medicare Agent's Information: If your state is approved for Medicaid, the Medicaid agent who is collecting state information will add this information to your online record (your address and phone number) and add to your Medicaid Enrollment Information form. The agent who is collecting information must also send you an enrollment agreement form, and a new Enrollment Waiver form if you have not signed a written consent.

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