Medicaid Services Interest Form

Medicaid Services Interest Form

This is not part of the referral process. This is so we can assess if we would be a good fit as your service provider.
Name of individual seeking Medicaid services*

Participant First NameParticipant Last Name
Name of person completing this form (if other than Individual seeking services)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Town/City individual seeking services lives in *
Has Medicaid Services in NC (Innovations Waiver or 1915i)Has Medicaid Health Insurance onlyDoes not have MedicaidUnsure
If you selected:
- Has Medicaid Health Insurance only
- Does not have Medicaid
- Unsure
PLEASE DO NOT COMPLETE THIS FORM.

please visit this website for more assistance and to get started: https://medicaid.ncdhhs.gov/beneficiaries

or call 888-245-0179
If you have Medicaid services, please continue with this form.
Innovations Waiver Tailored Plan1915iUnsure
Care Management Agency (CMA) [if you do not know, please answer unsure]*
Service Provider Agency (i.e. Autism Society, Maxim, Abound, Easter Seals, etc.) [if you do not know, please answer unsure]*
Community Living & Supports (CLS)RespiteSupported EmploymentAlternative Family Living (AFL)/Supported LivingCommunity NetworkingUnsure
Participant has Relative as Direct Employee (RDSE) as staff employed by current provider and would like them to be hired by TDASParticipant has other staff employed by current provider and would like them to be hired by TDASParticipant has staff currently, but is not referring them to TDASParticipant has no staffParticipant has potential staff they would like to refer for hire
EIPD/VR Supported Employment or Project SEEBuilding Abilities Day Program or Summer CampCommunity Programs (Supported Retirement, Every Voice Choir, TSAN, Petals with a Purpose, TD&AU Classes)Mental Health ServicesMedicaid Services (wishing to bring services back)None
Please list any TDAS staff you have spoken to regarding Medicaid Services.
Anything else you'd like us to know?
MCO, Care Manager, Other ProviderOther professional (doctor, teacher, etc.)Friend or Family memberResource Fair/Community EventSearched online/TDAS websiteOther
If you chose other, please explain
Thank you for completing this form. Triangle Disability & Autism Services staff will be in touch with you soon.

We appreciate your patience.
Should be Empty: