Fillable DHB 4037 DMA 4037.pdf (North Carolina)

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DHB 4037 DMA 4037.pdf (North Carolina)

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DHB-4037 (Rev. 08/20)
DISABILITY DETERMINATION TRANSMITTAL Received in DDS: ___________
Mail to: DISABILITY DETERMINATION SERVICES Aid Program/Category: _______
2802 Mail Service Center County No: _____
Raleigh, NC 27699 Application No: _____________
Attn: Medicaid Unit 09, 42, 44, or 45 Application Date: ___________
Name and Address of Applicant:
Worker:
Worker Direct Phone# & Ext.:
Date Submitted:
Social Security Number:
MAO (DMA-5009 and 5028 attached)
Retroactive Coverage Needed
SA – Certain Disabled (DMA-5006 and 5009 attached)
SA (DMA-5009 and 5028 attached)
Review Needed: Medical Re-exam established
Prior file attached per MA-2525, IV.B.4
Date of Birth:
Sex:
Phone Number:
REMARKS
ADDITIONAL INFORMATION. Associate with application previously
submitted on __________________________
PRIOR ACTION
Application Denial
Review Termination
Ongoing
Original date of application: __________________________________________ ___________________________________
Pursuant to Provisions of: Social Security Act (Medical Assistance Only)
North Carolina Disability/Incapacity Regulations
It is determined that the applicant is:
Under a disability since _______________
Not under a disability
Continuing disabled
Not continuing disabled
Incapacitated
Not incapacitated
Diagnosis:
Primary:
Code No:
Other:
DIARY/RE-EXAM
Type:
Mo/Yr:
Reason:
Reg. Basis Code
Vocational Background
Occ
Yrs.
Ed Yrs.
VR Referral
Previously Referred
Recommended
Not Recommended
RATIONALE:
See Attached
______________________________________
Date Case Released
______________________________________ ______________________________________
Disability Examiner Date Medical Examiner Date
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DHB 4037 DMA 4037.pdf (North Carolina)

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Completed 1 February 2022

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