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Use this simplified form to provide household contact and applicant information, eligibility details, and required identifiers such as Social Security number when available. Coverage applies for North Carolina residents with qualifying citizenship or immigration status and no Medicaid, Medicare, or other coverage, and ends when the federal public health emergency ends.",{"@graph":63,"@context":110},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/covid-19-testing-group-simplified-application-complete-nc-medicaid-application/305937/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/covid-19-testing-group-simplified-application-complete-nc-medicaid-application/305937.png","ImageObject",442,249,{"name":88,"@type":89},"Lucas Vance","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-14","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"When does health coverage end and what does it include?","Question",{"text":108,"@type":109},"Coverage ends when the federal Public Health Emergency ends. Effective March 11, 2021, coverage also pays for vaccinations and COVID-19 treatment, including treatment of a condition that may seriously complicate COVID-19 treatment.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},305937,1790440749,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":121,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":9},549768064622,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","NC Medicaid Application for (COVID-19) Medical Assistance  \nComplete this application to get help paying for certain coronavirus (COVID-19) testing costs, vaccines and coverage for Covid-19 treatment. Do not include people on this application who are not seeking coverage for COVID 19 tests. In order to be eligible for COVID-19 Testing Medical Assistance:  \nLive in North Carolina  \nBe a U.S. Citizen or U.S. National or have eligible Immigration status  \nNot be covered by Medicaid, Medicare, or health insurance  \nThe health coverage you will get if you are found eligible using this application will end when the Federal Public Health Emergency ends. Effective March 11, 2021, health coverage will also pay for vaccinations and COVID-19 treatment (including treatment of a condition that may seriously complicate the treatment of COVID-19) .  \nTo see if you are eligible for other health care benefits and services through Medicaid, CHIP or the Marketplace, you should complete a full application at ~~[~~[https://medicaid. ncdhhs.gov/beneficiaries/get-started/apply-medicaid-or-health-choice](https://medicaid. ncdhhs.gov/beneficiaries/get-started/apply-medicaid-or-health-choice), at your county DSS, online at [https://epass. nc.gov/ or go to](https://epass. nc.gov/ or go to) [Healthcare.gov](Healthcare.gov).  \nCONTACT INFORMATION  \nOne adult in the family should be the contact person. The contact person does not have to be applying for coverage.  \nIf you do not have an address, your mail will go to your local Department of Social Services.  \n\n| 1. First Name |  | 2. Middle Name | 3. Last Name |  |  |  | 4. Suffix |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| 5. Home Address (leave blank if you don’t have one) |  |  | 6. City |  | 7. State |  | 8. Zip |\n| 9. Mailing Address (if different from home address) |  |  | 10. City |  | 11. State |  | 12. Zip |\n| 13. County of Residence | 14. Phone Number |  | 15. Email address |  |  |  |  |\n| 16. Is this the address for the individuals applying?\u003Cbr>☐ YES ☐ NO If no, go to 18 |  |  | 17. Preferred language | 18. Date of Birth |  | 19. Gender\u003Cbr>☐ M ☐F |  |\n| 20. Applicant Home Address, if different from 5 above |  |  | 21. City State Zip |  |  |  |  |\n| 22. Applicant Mailing Address, if different from 9 above |  |  | 23. City State Zip |  |  |  |  |\n\nTELL US ABOUT ALL THE PEOPLE WHO WANT TO APPLY  \nPerson 1: (You, if you are applying for yourself)  \n\n| 24. First Name | 25. Middle Name | 26. Last Name | 27. Suffix | 28. Date of Birth | 29. Gender\u003Cbr>☐M ☐F |\n| --- | --- | --- | --- | --- | --- |\n| 30. Social Security Number (SSN)  \u003Cbr>We need your SSN if you want to apply for COVID-19 testing coverage and have an SSN or can get one. We use SSNs to check to see who’s eligible for help paying for health coverage. For more information on getting an SSN call 1-800-772-1213 or visit [socialsecurity.gov](socialsecurity.gov); TTY users should call 1-800-325-0778 |  |  |  |  |  |\n| 31. Are you a U.S. Citizen or U.S. National? ☐ YES ☐ NO If Yes, go to 36. If No, go to 32 |  |  |  |  |  |\n| 32. Are you a naturalized or derived citizen? If Yes complete a and b If No, go to 33   ☐ YES ☐ NO\u003Cbr>a. Alien Number   b. Certificate Number  |  |  |  |  |  |\n| 33. If you aren’t a U.S. Citizen or U.S. National, do you have eligible immigration status?   ☐ YES ☐ NO If Yes, Enter document type and ID number below. If no, go to 34. |  |  |  |  |  |\n\n\n| a. Immigration document type b. Status type (optional) c. Name as it appears on your immigration document |\n| --- |\n| d. Alien or I-94 number e. Card number or passport number |\n| f. SEVIS ID or expiration date (optional) g. Other (Category code or country of issuance) |\n| 34. Have you lived in the US since 1996?   ☐ YES ☐ NO |\n| 35. Are you, or your spouse or parent, an honorably discharged veteran or an active-duty member of the US military?\u003Cbr>   ☐ YES ☐ NO |\n| 36. If Hispanic/Latino, ethnicity (OPTIONAL – check all that apply)\u003Cbr>□ Mexican □ Mexican-American □ Puer","cbCaiikmX5xmUeTa","https://ap.wps.com/l/cbCaiikmX5xmUeTa","pdf",323281,"English","# Contact Information\n## Address and Preferred Language\n# Individual Applicant Details\n## Eligibility and Demographics\n## COVID-19 Testing in Last 3 Months\n# Additional Applicants\n## Family Member Coverage Information","[{\"question\":\"When does health coverage end and what does it include?\",\"answer\":\"Coverage ends when the federal Public Health Emergency ends. Effective March 11, 2021, coverage also pays for vaccinations and COVID-19 treatment, including treatment of a condition that may seriously complicate COVID-19 treatment.\"}]","COVID-19 Testing Group Simplified Application - Complete NC Medicaid Application | PDF",1789831093]