2011-2025 Form

What is the DSS 1678 Replacement Affidavit Info Dhhs State Nc

The DSS 1678 Replacement Affidavit is a legal document used in North Carolina to request a replacement for a lost or stolen Medicaid card. This form is essential for individuals who need to access healthcare services covered by Medicaid but do not have their card available. The affidavit serves as a formal declaration of the circumstances surrounding the loss, ensuring that the state can process the request efficiently and securely.

How to obtain the DSS 1678 Replacement Affidavit Info Dhhs State Nc

To obtain the DSS 1678 Replacement Affidavit, individuals can visit their local Department of Health and Human Services (DHHS) office or access the form online through the North Carolina DHHS website. It is important to ensure that you are using the most current version of the form to avoid any delays in processing your request. Additionally, local offices may provide assistance in completing the form if needed.

Steps to complete the DSS 1678 Replacement Affidavit Info Dhhs State Nc

Completing the DSS 1678 Replacement Affidavit involves several steps:

• Begin by filling out your personal information, including your name, address, and Medicaid identification number.
• Clearly state the reason for the request, detailing how the card was lost or stolen.
• Provide any additional information that may be relevant to your situation, such as police reports if applicable.
• Sign and date the affidavit to certify that the information provided is accurate.

Once completed, submit the form to your local DHHS office for processing.

Legal use of the DSS 1678 Replacement Affidavit Info Dhhs State Nc

The DSS 1678 Replacement Affidavit is legally binding and must be completed truthfully. Misrepresentation or falsification of information on this affidavit can lead to legal consequences, including penalties or denial of services. It is crucial to ensure that all details are accurate and that the affidavit is signed by the individual requesting the replacement card.

Key elements of the DSS 1678 Replacement Affidavit Info Dhhs State Nc

Key elements of the DSS 1678 Replacement Affidavit include:

• Personal Information: Name, address, and Medicaid ID number.
• Reason for Replacement: A clear explanation of how the card was lost or stolen.
• Signature: The signature of the individual requesting the replacement, affirming the truthfulness of the information.

These elements ensure that the affidavit is complete and meets the requirements set forth by the North Carolina DHHS.

State-specific rules for the DSS 1678 Replacement Affidavit Info Dhhs State Nc

In North Carolina, specific rules govern the use of the DSS 1678 Replacement Affidavit. Individuals must submit the form to their local DHHS office, where it will be reviewed for completeness and accuracy. Additionally, the state may require supporting documentation, such as identification or proof of Medicaid eligibility, to process the request. Familiarity with these rules helps ensure a smooth application process.