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NC Division of Health Service Regulation
Adult Care Licensure Section
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Adult Care Licensure Section
Forms and Applications
Forms and Applications
The following forms are used by adult care and family care homes.
Licensure of an Adult Care or Family Care Facility
Registration of Multi-Unit Assisted Housing with Services
Provider Forms
Administrator Certification
Continuing Education
Medication Testing
Publication Request Form
(PDF, 40 KB)
Licensure of an Adult Care or Family Care Facility
Initial License Application
(PDF, 87 KB)
Policy and Procedure Checklist for Initial Licensure
(PDF, 58 KB)
Adult Care Change Licensure Application
(PDF, 219 KB)
Family Care Change Licensure Application
(PDF, 155 KB)
Registration of Multi-Unit Assisted Housing with Services
Disclosure Requirements and Annual Registration
(PDF, 26 KB)
Provider Forms
N.C. Licensed Care Facilities Disaster Plan Template
Instructions for ISO files
Disaster Plan Template
(ISO, 358 MB)
DMA 3050R - Adult Care Home Personal Care Services (PCS) Physician Authorization and Plan of Care
(PDF, 36 KB)
Food Service Orientation Manual
(PDF, 106 KB)
Resident Register
(PDF, 48 KB)
Death Reporting Form
(PDF, 30 KB)
Resident Assessment Manual
(PDF, 101 KB)
DMA-9053 - Adult Care Home Hearing Request Form
(PDF, 81 KB)
DMA-9052 - Adult Care Home Notice of Transfer/Discharge
(PDF, 15 KB)
DMA Administrative Hearings and Appeals
Administrator Certification
Assisted Living Administrator Certification Requirements and Guidelines
Assisted Living Administrator Certification Application
(PDF, 14 KB)
Family Care Home Administrator Qualifications Application
(PDF, 43 KB)
Administrator-In-Training (AIT) Preceptor Guidelines
Continuing Education
Continuing Education Course Guidelines
Continuing Education Course Approval Form
(PDF, 29 KB)
Medication Testing
Instructions for Completing the Registration Form
Instructions for Medication Testing
Medication Administration Checklist and Instructions
(PDF, 164 KB)
Facility Star Ratings
Star Rating Program
Adult Care Home Violations and Penalties
Listing of Facilities with Penalties
Facility Licensure Information
Staff and Contacts
Branch Office Territories
Facility Listings
Announcements
Rules
Frequently Asked Questions
Medication Testing Information
Administrator Certification and Forms
Continuing Education Course Information
Training Opportunities
Informal Dispute Resolution Procedures
Forms and Applications
