The NC CMARC referral form is a one-page PDF you download from the NC Medicaid website, fill out with the child’s and caregiver’s information, and send to the local health department in the child’s county of residence. The standard version is called the CMARC Checklist Referral Form.1North Carolina Department of Health and Human Services. CMARC Checklist Referral Form V1 Anyone can submit it — a parent, pediatrician, hospital, social worker, or community provider — and the services it connects a child to are free.
Which Children Qualify
CMARC serves North Carolina children from birth through age five, with or without Medicaid. A child fits the program if they fall into one or more of these groups:
- Children with special healthcare needs — a chronic physical, developmental, behavioral, or emotional condition expected to last at least 12 months and requiring more care than children generally need.
- Infants who spent time in a neonatal intensive care unit.
- Children exposed to adverse childhood experiences, including foster care, a history of abuse or neglect, household substance abuse, domestic violence, an incarcerated parent or caregiver, caregiver mental health conditions (including postpartum depression), homelessness or unstable housing, and unsafe living environments.
- Infants identified as substance affected through a Child Protective Services Plan of Safe Care.
Children with long-term conditions like asthma, those without a stable primary care provider, and those with high emergency department use also fit the target population.2NC Medicaid. Care Management for At-Risk Children (CMARC)
Who Can Submit a Referral
You do not need to be a doctor or social worker. The referral can come from the hospital where the child was born, the child’s pediatrician, a community service provider, or a parent or guardian.3Wake County Government. Care Management for Early Childhood If you are a parent and your child fits one of the categories above, you can download the form, complete it yourself, and send it to your county’s health department.
Where to Get the Form
Download the CMARC Checklist Referral Form as a PDF from the NC Medicaid website.1North Carolina Department of Health and Human Services. CMARC Checklist Referral Form V1 A second document, the CMARC Referral Screening Form, is posted on the same page.2NC Medicaid. Care Management for At-Risk Children (CMARC) Some counties use a locally branded version with the same fields, and your health department can give you a blank copy if you prefer not to download one.
How to Fill Out the Form
The form is short. Getting the details right the first time keeps the referral from stalling at intake.
Child and Caregiver Information
Start with the child’s first and last name, date of birth, and the date you are making the referral. Check the insurance box that applies: Medicaid, Health Choice, private insurance, or uninsured. If the child has Medicaid, enter the Medicaid ID number. Leave that field blank if the child is uninsured or privately insured; the absence of a Medicaid ID does not disqualify anyone.4North Carolina Department of Health and Human Services. Care Management for At-Risk Children
Below the child’s details, fill in the caregiver’s street address, city, zip code, and county, plus a home and cell phone number if both are available. The county field matters because it decides which local health department receives the referral.1North Carolina Department of Health and Human Services. CMARC Checklist Referral Form V1
Medical Home and Referring Provider
Enter the name and contact information for the child’s pediatrician or primary care clinic so the care manager can coordinate with them. If the child does not have a regular doctor, write that in — connecting families with a medical home is part of what the program does.
If someone other than the parent is completing the form, that person’s information goes in the separate referring provider section so the care management team knows who initiated the referral.
Target Population Checkboxes
This section is why the referral exists. Check every category that applies rather than picking one:
- Child with Special Health Care Needs, for a chronic condition expected to last 12 months or more.
- NICU Infant, for a baby who spent time in a neonatal intensive care unit.
- Adverse childhood experiences, which has its own list of checkboxes covering foster care, abuse or neglect history, caregiver substance abuse, domestic violence exposure, an incarcerated parent, caregiver mental health issues, homelessness, and unsafe living conditions.
If the referral involves a substance-affected infant through a CPS Plan of Safe Care, the form has a dedicated section for that. Complete it fully; incomplete Plan of Safe Care referrals are a common reason for intake delays.1North Carolina Department of Health and Human Services. CMARC Checklist Referral Form V1 A child who was in the NICU and is now in foster care qualifies under both categories, and marking both gives the care manager the full picture from day one.
Where to Send the Completed Form
Submission procedures vary by county.4North Carolina Department of Health and Human Services. Care Management for At-Risk Children Most counties receive referrals by secure fax; some use secure electronic portals. To find the right fax number, email, or contact person, download the CMARC Referral and Supervisor Directory from the NC Medicaid website; the most recent version is dated April 2026.2NC Medicaid. Care Management for At-Risk Children (CMARC) If you cannot locate the directory or are unsure which county handles the referral, call the NC Medicaid Contact Center at 888-245-0179.
The form always goes to the health department in the county where the child lives, not where the referring provider is located.
What Happens After You Submit
The local health department reviews the referral and assigns a care manager, typically a social worker or registered nurse. The care manager contacts the family to schedule an initial assessment and build a personalized plan of care.5Cabarrus Health Alliance. Care Management for At-Risk Children (CMARC) Ongoing support happens through home visits, phone calls, and attendance at doctor’s appointments, with the mix shaped by what works for the family. Care managers answer health questions, connect families to resources like food assistance or housing programs, coordinate with the child’s healthcare provider, and provide parenting education.
Cost
CMARC is free. Every child who meets the eligibility criteria can enroll at no charge, whether they have Medicaid, Health Choice, private insurance, or no insurance.4North Carolina Department of Health and Human Services. Care Management for At-Risk Children The insurance question on the form helps the care manager coordinate with existing coverage, not screen the family out.
Age Limit
CMARC covers children from birth through age five. Once a child turns six, they are no longer eligible. If your child is approaching that limit and still has ongoing needs, ask the care manager about school-based or community follow-up services before the transition.2NC Medicaid. Care Management for At-Risk Children (CMARC)