The NC Medicaid CCNC/CA enrollment form, officially the DMA-9006, is the one-page document you use to choose or change your primary care provider under the Carolina ACCESS program in NC Medicaid Direct. You fill in your Medicaid information and your chosen provider’s details, sign it, and send it by mail or fax to the Department of Social Services in your county.1NC Medicaid. CCNC/CA Enrollment Form The form links you to a specific medical home so your routine and specialty care is coordinated through one practice.
Before anything else, confirm this is the right form for you. It is for people in NC Medicaid Direct. If you are in an NC Medicaid Managed Care Standard Plan, you pick a provider through your health plan. If you are in a Behavioral Health and I/DD Tailored Plan — including anyone in the NC Innovations Waiver, TBI Waiver, or Transitions to Community Living program — the DMA-9006 does not apply to you.2North Carolina Department of Health and Human Services. Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans
Pick a Provider With an Open Panel First
The step that trips people up happens before the pen touches the form. You need a primary care provider who participates in Carolina ACCESS and still has room on their patient panel. Use the NC Medicaid Provider and Health Plan Lookup Tool at ncmedicaidplans.gov to search by location for providers who accept NC Medicaid Direct.3NC Medicaid. Find a Doctor To verify a specific practice, search the NCTracks Enrolled Practitioner Search by name, NPI, or license number.4NCTracks. Enrolled Practitioner Search
Providers set limits on how many Medicaid patients they take. A panel may be closed because the practice has hit its cap, because the provider is under sanction, or because the health plan closed it over access concerns.5NC Medicaid. Fact Sheet Panel Management for Primary Care Providers Call the office directly and ask whether they are accepting new Carolina ACCESS patients. If you submit the form naming a provider whose panel is full, your selection will be denied.
What to Have Ready
Pull these items together before you start writing:
- Your Medicaid ID number, exactly as printed on your NC Medicaid card
- Your full legal name, date of birth, address, and phone number
- Your county of residence
- The provider’s name and practice address
- The provider’s National Provider Identifier, a ten-digit number assigned by the federal government and searchable through the NPI Registry at npiregistry.cms.hhs.gov6Centers for Medicare & Medicaid Services. National Provider Identifier Standard7NPPES NPI Registry. About the NPI Registry
Keep your Medicaid card in front of you while you write so the ID number copies over cleanly. A single transposed digit is the easiest reason to get a form sent back.
Filling Out the DMA-9006
Download the form from the NC DHHS policies site or the NC Medicaid forms page.8NC DHHS. DMA-9006 Carolina ACCESS Enrollment Form for Recipients of Medicaid and Health Choice A blank copy is also available at your local Department of Social Services office.9NC Medicaid. Community Care of North Carolina
At the top, enter the date and your county. In the personal information section, write your legal name, address, phone number, and Medicaid ID number. In the provider section, enter the name, NPI, and practice address of the provider you selected. If you are enrolling more than one person in the household, each person’s information needs to appear on the form with their own Medicaid ID number.
The form has checkboxes to confirm you have received the Carolina ACCESS handbook and informational handouts. Check the ones that apply. At the bottom, the patient or head of household must sign and date the form. The signature authorizes the provider assignment and confirms the information is accurate. An unsigned form will be returned.
Where to Send It
Mail or fax the completed form to the Department of Social Services in the county where you live.1NC Medicaid. CCNC/CA Enrollment Form Those are the two submission methods the form itself lists. County DSS mailing addresses, fax numbers, and locations are in the NC DHHS local offices directory.9NC Medicaid. Community Care of North Carolina Some county offices accept walk-in drop-offs, but call ahead to confirm.
Faxing has a practical advantage: the transmission confirmation page is proof you sent it and when. If you mail, address it to the Medicaid intake division at the DSS rather than to a general county address. Either way, keep a photocopy of the signed form and a note of the submission date. That copy is your evidence if anything gets lost.
After You Submit
County DSS staff verify your Medicaid eligibility and confirm the provider you picked has an open panel. If both check out, the provider assignment is entered into the statewide NCTracks system, and you should receive a mailed confirmation notice showing your new primary care provider’s name and contact information.
If you never choose a provider, you will not stay unassigned. After additional notifications, NCTracks auto-assigns beneficiaries to a primary care practice based on past provider history, where you have previously received care, and your geographic location.10NC Medicaid. Managing Your Primary Care Assignments Submitting the DMA-9006 yourself is the only way to guarantee you end up with the provider you actually want.
If no confirmation arrives within about six weeks, contact your county DSS caseworker to check the status. The caseworker can tell you whether more information is needed or whether a backlog is holding things up. Once the assignment is confirmed, your primary care provider can bill NC Medicaid for services under the Carolina ACCESS agreement.
Changing Providers Later
To switch primary care providers after your initial enrollment, submit a new DMA-9006 the same way: fill it out with the new provider’s information and mail or fax it to your county DSS.9NC Medicaid. Community Care of North Carolina The same prerequisites apply. Confirm the new provider participates in Carolina ACCESS and has room on their panel before you send the form. A panel that was closed last time you looked may have openings now, so it is worth checking again if your first choice was full.