Information and Resources on Hurricane Helene. Are you in North Carolina and need help because of Hurricane Helene? View the DPS website for helpful information.
Member Materials and Forms
Reference Materials
Quick Reference Guide (QRG)
Reference Materials
- 2024 Transparency Notice
- 2023 Transparency Notice
- Women's Health and Cancer Rights Act Annual Notice
- Statement of Non-Discrimination
- Interoperability and Patient Access
- Cost Comparison Tool
- Wellness and Health Information
- Preventive Services Guide (PDF)
Forms
- Grievance and Appeals Form (PDF)
- Member Reimbursement Medical Claim Form (PDF)
- Member Reimbursement Form - OTC Covid Test (PDF)
- Donor Transplant Travel Reimbursement Form (PDF)
- Recipient Transplant Travel Reimbursement Form (PDF)
- Authorization to Disclose Health Information Form - English (PDF)
- Authorization to Disclose Health Information Form - Simplified Chinese (PDF)
- Authorization to Disclose Health Information Form - Traditional Chinese (PDF)
- Authorization to Disclose Health Information Form - Vietnamese (PDF)
- Revocation of Authorization Form (PDF)
- Prescription Claim Reimbursement Form (PDF)
- Authorized Representative Designation Form (PDF)