Important Forms

Overview

File a claim. Order prescription drugs. All the forms you need for communicating with the State Health Plan are listed below. Indemnity plan forms are located under Health Plan Options -- Indemnity Plan Archive -- Forms.

Enroll in a plan
Learn how to enroll, including instructions and application forms.

Update Your Information
Change your name or address, or add and remove dependents.

Authorize a Representative
Give someone permission to access your health information.

Notice of Privacy Practices
Learn how medical information about you may be used and disclosed and how you can get access to this information.

Request Reimbursement
Access various types of claim forms.

Appeal a Decision
Dispute the way a claim was paid.

Order Prescription Drugs
Request that your prescription be filled by mail.

Special Care Pharmacy Fax Form (PDF, 118KB)
Request a specialty medication through Medco.

Flexible Benefit Plan (Section 125) Rejection Form (PDF, 111KB)
Learn how to opt out of the Flexible Benefit Plan, IRS Section 125.

Subrogation - Third Party Recovery
Recover medical expenditures incurred by the State Health Plan where a third party is liable.

Reimburse the State
Pursue claims paid by the State Health Plan where a third party is liable.

NC Health Choice Forms
Access forms specific to the NC Health Choice for Children program.