NCHC Enrollment Fee Notice
__________________County
DATE _____
___________________
CASE HEAD ________________________
ADDRESS _______________________________
_______________________________
APPLICATION NUMBER _________________
We have determined that the child(ren) for whom you filed an application for medical care is eligible for NC
Health Choice. Your family income is above 150% of the federal poverty level; therefore, State law requires
payment of an annual enrollment fee to obtain NC Health Choice Coverage. The enrollment fee is
$______________ and must be paid by ___________________
, or the application will be denied. If we must
deny the application because of failure to pay the enrollment fee, you will have to file a new application to obtain
health care coverage.
Bring
this letter with your enrollment fee to your local County Department of Social Services, or mail this letter
and your enrollment fee _____________________________________________________
_________________________________________________________________________________.
Your payment must be paid in full by:
Cash
Mo
ney Order
Certified Check
Personal Check
Parti
al payments will not be accepted.
_____________
_________________
Income Maintenance Caseworker
Telephone Number __________________________
Official Use Only
Date
of Payment _________________
Amount Paid _________________
________________________________
Signature of Collector
Copy
to: Applicant
County File
Collector
click to sign
signature
click to edit
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