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NC FL2 Form (NC Medicaid-372-124)

North Carolina's FL2 is the physician's level-of-care form for nursing facility, adult care home and other long-term care placement. On one page it records diagnoses, current and requested level of care, functional and behavioral status, special care needs and medications. It supports NCTracks level-of-care prior approval, where it is uploaded as an attachment to a request already entered.

Who completes it

The attending physician, or a physician assistant or nurse practitioner, completes the clinical content and signs and dates the form. Recipient and facility details at the top, including the PASRR number, are part of the same page.

Submitting and payment

How to submit it
The facility uploads the signed FL2 as an attachment to a level-of-care PA request already entered in the NCTracks Provider Portal; the FL2 cannot create a PA request by itself. The facility keeps the form on file.

Good to know

  • Requested level of care options include nursing facility, NF rehab, ventilator care, specialty hospital rehab, extended care, out-of-state NF or ventilator, and CAP/CH or CAP/DA levels.
  • The FL2 has a field for the PASRR number, which comes from the separate NC Level I PASRR screening for nursing facility placement.
  • Diagnoses need the code and description with onset dates, and medications need name and strength, dosage and route, with room for twelve.
  • Related forms: DMA-0100 Physician's Signature for Authorization of Level of Care, and NC Medicaid-2039 for notifying the health plan of a nursing facility level of care.

Get the official form

Download the current version from the source each time; forms change without notice.

NC Medicaid Long Term Care FL2 Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign an NC FL2?

The FL2 is completed by the attending physician, and a physician assistant or nurse practitioner may also complete it. The signature line reads Physician's Signature, with a date. The signer certifies the diagnoses, requested level of care, care needs and medications recorded on the page.

How is the FL2 submitted in NCTracks?

It is not a standalone request. NCTracks says the FL2 should be uploaded as an attachment to a prior approval request already entered in the secure NCTracks Provider Portal, and it cannot be used to create a PA request. The facility keeps the signed form.

What is the FL2 form number?

The current form is NC Medicaid-372-124, dated 9.2018. The NC Medicaid adult care home forms page lists it as Adult Care Home FL-2 (DMA372-124), and NCTracks lists it as the Long Term Care FL2 Form.