Patient Statement of Primary Insurance Coverage
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Patient's Name
Address
Parent/Guardian Name (If Applicable)
Medicaid Plan Provider

I, the undersigned, hereby confirm that North Carolina Medicaid is my primary insurance coverage. I do not have any other active insurance that should be billed as primary. Any previously identified insurance plans are no longer valid.

This statement serves as an update to my benefits coordination and is intended to ensure that my Medicaid coverage is properly recognized as the primary insurance on file.

I understand that this information will be submitted to the Medicaid office by Magnolia Health, PLLC for verification.

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