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Free North Carolina Department Of Insurance Form

The North Carolina Department of Insurance Uniform Application To Participate as a Health Care Practitioner is a standardized form required for health care providers seeking to contract with insurers that offer health benefit plans. This application ensures that all necessary information is collected for proper credentialing and compliance with state regulations. To begin the process, fill out the form by clicking the button below.

Open North Carolina Department Of Insurance Editor Here

Free North Carolina Department Of Insurance Form

Contents

The North Carolina Department of Insurance Uniform Application to Participate as a Health Care Practitioner is an essential document for healthcare providers seeking to join an insurer's network. This application is mandated by North Carolina General Statute 58-3-230, ensuring that all insurers offering health benefit plans use a standardized form for credentialing providers. Applicants must complete all sections of the form, marking any non-applicable questions with "N/A." The form requires various supporting documents, including copies of state licenses, DEA certificates, and proof of professional liability insurance. Applicants must also provide demographic information, such as their name, date of birth, and practice details, including office addresses and hours of operation. The application emphasizes the importance of thoroughness; incomplete submissions can lead to delays in the credentialing process. Additionally, only the Commissioner of Insurance can authorize modifications to the form, which underscores its standardized nature. This application serves as a crucial first step for healthcare practitioners aiming to provide services within the state's health insurance framework.

Sample - North Carolina Department Of Insurance Form

FINANCIAL ASSISTANCE APPLICATION	Patient Name _______________________
Applications without documentation will be denied.	Account# __________________________

Automatic Qualifier (subject to verification)

If you receive one of the following benefits,

Fill out the Section 1a & c, sign the application and mail with documentation

▪FOOD STAMPS (applies to any household member)

Send a copy of your most current DHS food stamp verification letter. (Do not sent copies of food stamp cards or printouts of food stamp accounts)

▪MEDICAID/SOONERCARE (applies to any household member)

Send a copy of your Medicaid/SoonerCare letter or case number

▪SOCIAL SECURITY DISABLITY (applies only to the patient)

Send a copy of your Social Security Notice of Income letter

If you DO NOT receive any of the above benefits, please fill out the entire application and provide the following documentation.

NOTE: All documentation provided for this application is confidential. It is used exclusively for this application. Excluding the information needed to verify credit history, this information it is not shared with third parties or other NRHS departments.

HOUSEHOLD INCOME: Send written verification of your household’s income for the past twelve (12) months.

●Each household wage earner must be included. (not needed if the paycheck stub gives year to date earnings) PAYCHECK: Send a copy of the most current paycheck stub for each household wage earner.

CHECKING AND SAVINGS ACCOUNT: Send copies of your last three (3) months checking account statements or a 90 day printout showing transactions and balances, and a copy of your most recent savings account statement.

●If you DO NOT have a bank account, send a copy of your most recent mortgage/rent and utility receipt.

FEDERAL INCOME TAX RETURN Send a completed, signed copy of last year’s Income Tax Return for each household wage earner, include all schedules, W-2’s, and 1099’s.

●If you DID NOT FILE an income tax return for the last tax year, please provide IRS verification.

FULL TIME STUDENTS: Provide verification of enrollment and a copy of your Financial Aid Notification (FAN) letter. INTERNATIONAL STUDENTS, Send a copy of your Form I-20 provided to your college / university.

For Hospital Use Only

	Approved:	Approved:	Approved:

	%:	%:	%:
Determination:
	Date:	Date:	Date:

(Initials Only)
(Initials Only)
	Denied:	Denied:	Denied:

	Date:	Date:	Date:

Reasons:

________________________________________________________________________________________________________________

920500005.0210

Page 1 of 4

1. HOUSEHOLD

a)APPLICANT (PARENT/GUARDIAN, IF PATIENT IS A MINOR):

FIRST NAME	MIDDLE INITIAL	LAST NAME	SOC SEC#		BIRTHDATE

MAILING ADDRESS	CITY, STATE, ZIP	How long?	Circle one	Phone number:
			OWN RENT	(	)
Previous Address, if at current address less than 1 year.

EMPLOYER	STREET ADDRESS:		Start date , if less than 1 year
			(Month/Day/Year)

Gross Monthly Salary:			How often are you paid - circle one
			Monthly Bi-Weekly		Weekly

If Self-employed, complete the following line and submit proof of income:

Name of Business	Street Address		Phone Number
b) SPOUSE:
FIRST NAME	MIDDLE INITIAL	LAST NAME	SOC SEC#	BIRTHDATE

EMPLOYER	STREET	ADDRESS	Start date , if less than 1 year
			(Month/Day/Year)

Gross Monthly Salary:			How often are you paid? - circle one
			Monthly Bi-Weekly	Weekly

c)OTHER HOUSEHOLD MEMBERS HOUSEHOLD TOTAL: _________

NAME	RELATION TO PT	SOC SEC#	MEDICAID OR CASE NUMBER

Name of Nearest Relative (Not living with you) RelationAddressPhone Number

920500005.0210

Page 2 of 4

2. ASSETS:

BANK ACCOUNTS: If sending a printout, it must cover a 90 day period and show the running balance. If necessary, print in landscape mode. All but the last four digits of the account number may be blacked out.

Checking Account#		Bank Name		Current Balance

Checking Account#		Bank Name		Current Balance

Savings Account#		Bank Name		Current Balance


PROPERTY (include primary residence, other residences, rental/business property, out of state property)
Property Address		County/State	Type	Current Market Value	Amount owed



VEHICLES:
Make/Model			Value	Amount Owed
Make/Model			Value	Amount Owed
3. MONTHLY EXPENSES (estimate, if necessary):
Rent/Mortgage:				Credit Cards:
Utilities:
(Gas, Electric, Water)
Food:
Auto Expense
Payment: _______________________
Payment: _______________________				Medical Expenses:
Fuel:	_______________________
Maintenance: ____________________
Maintenance: ____________________

Other:

If you do not qualify for NRHS’ Financial Assistance Program, what is your proposed monthly payment? __________

Norman Regional Health System is authorized to check my credit history and to report to others its credit experience with me.

I certify that the above information is correct and I hereby authorize the Norman Regional Health System to verify all the above information and I authorize any third party to release to Norman Regional Health System any information required to verify and authenticate this application.

I understand that in order to process this application additional information may be needed and it must be provided by me when requested. I understand that failure to do so will result in an automatic denial.

The application must be RECEIVED WITHIN 21 DAYS OF DAY IT WAS MAILED TO YOU or the application will be denied.

___________________________________		_________________________________________
Applicant’s Signature	Date	Spouse’ Signature	Date

Applications must be mailed. We cannot accept faxed or e-mailed copies. Mail the SIGNED application and

documentation to: Norman Regional Health System, Att: PFS, PO BOX 1308, Norman OK 73070-1308.

For questions call 405-307-1318
920500005.0210	Page 3 of 4

COMMENTS:

__________________________________________________________________________________________

92050005.0210

Page 4 of 4

⇩ North Carolina Department Of Insurance PDF Form

File Breakdown

Fact Name	Details
Governing Law	This form is governed by North Carolina General Statute 58-3-230, which mandates its use by insurers providing health benefit plans.
Submission Instructions	Applicants must send completed forms directly to the organizations they wish to contract with, rather than submitting them to the Department of Insurance.
Required Information	The form must be filled out completely, with "N/A" indicated for any non-applicable questions. Incomplete applications may lead to delays.
Authorization for Changes	Only the Commissioner of Insurance has the authority to make changes to this form, ensuring its integrity and compliance.
Documentation Requirements	Applicants must attach several documents, including copies of licenses, DEA certificates, and proof of professional liability insurance, among others.
Last Updated	The form was last updated in June 2005, indicating the need for applicants to verify that they are using the most current version.

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