Carobell requires a severe or profound Intellectual Developmental Disability Diagnosis for admission.  North Carolina Medicaid is required.  Carobell can assist with the Medicaid application process.

APPLICANT INFORMATION

 
PARENT INFORMATION

   
FINANCIAL RESOURCES INFORMATION

Public funds may be used only if and when other sources of first and third party payment have been exhausted.  Carobell is responsible for establishing when a consumer has private insurance available, and we will assist the consumer in the coordination of private health care benefits.  Carobell will also be responsible for billing private insurance when applicable.

Insurance Information
Please complete the following Insurance Information.  Do not leave any area blank.  If an area does not apply, please mark it N/A.

Entitlement Information
Please list monthly income from each applicable resource.  If none, then mark N/A.

APPLICANT'S MEDICAL INFORMATION

 
BEHAVIOR INFORMATION

 

If yes, please tell us how often and how intensive the behaviors. Leave blank if the Applicant does not exhibit the behavior.