PCAP Enrollment Referral

This referral form is to request an enrollment appointment for your PCAP clients for plan year 2025. You may also use it to request a Medicaid application appointment for your clients who require a denial in order to recertify for HMAP. NOTE: Navigators cannot assist with Medicaid applications for individuals with Medicare so please do not refer any SPAP enrollees via this form. If you have any questions, please reach out to the PCAP Navigators at PCAPNavigators@legalaidnc.org.

Please complete all fields below. For this referral form, "case manager" refers to the person who assists the client with their HMAP application and should be the point of contact if there are any questions regarding HMAP eligibility.

First Name Last Name

Date of Birth Preferred Language Pronouns

Client's Postal Code (use your agency's if you're not sure)

Case Manager's Email Client's Home/Mobile Phone

(Optional)