Forms and Applications

Acute and Home Care Licensure and Certification Section

• License Application for Home Care, Nursing Pool, and Hospice (PDF, 56 KB)
• Report of Death to DHHS form for state operated facilities, psych hospitals and psych units (PDF, 59 KB)
• Hospital restraint death reporting to CMS (PDF, 523 KB)

Adult Care Licensure Section

• Publication Request Form (PDF, 40 KB)
• 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, 184 KB)
• Disclosure Requirements for Multi-Unit Assisted Housing with Services and Annual Registration (PDF, 26 KB)
• 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)
• Resident Register (PDF, 51 KB)
• Death Reporting Form (PDF, 30 KB)
• DMA-9053 - Adult Care Home Hearing Request Form (PDF, 81 KB)
• DMA-9052 - Adult Care Home Notice of Transfer/Discharge (PDF, 35 KB)
• Resident Assessment Manual (PDF, 101 KB)
• 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 Course Guidelines
• Continuing Education Course Approval Form (PDF, 29 KB)
• Instructions for Completing the Registration Form
• Instructions for Medication Testing
• Medication Administration Checklist and Instructions (PDF, 164 KB)
• Guidelines for the Medication Adminstration Clinical Skills Checklist (PDF, 204 KB)

Complaint Intake Unit

• Complaint Form [DOC, 63 KB] [PDF, 75 KB]
• Report of Death to DHHS form for state operated facilities, psych hospitals and psych units (PDF, 39 KB)
• Critical Incident and Death Report Form for community mental health facilities (PDF, 139 KB)
• Death Reporting Form for adult care facilities (PDF, 36 KB)

Health Care Personnel Registry Section

• 24-Hour Initial Report (PDF, 52 KB)
• 5-Working Day Report (PDF, 68 KB)
• Application to be listed on the North Carolina Nurse Aide I Registry (RNs and LPNs only) (PDF, 52 KB)
• Clinical Site Approval Request for Nurse Aide I Training Program (PDF, 24 KB)
• Faculty Approval Form (PDF, 65 KB)
• Faculty Removal Form (PDF, 26 KB)
• Name/Address Change Reporting Form (PDF, 44 KB)
• Request for Replacement (Duplicate) Renewal Form (PDF, 43 KB)
• Nurse Aide I Training Program Application Packet (PDF, 153 KB)
• Geriatric Aide Training Program for Registry Listing Community College Approval Application (PDF, 39 KB)

Jails and Detention Section

• Confinement Report Form (PDF, 32 KB)
• Report of Inmate Death Form (PDF, 44 KB)

Medical Facilities Planning Section

• Substance Abuse Residential Facilities Form
• Registration and Inventory Forms

Mental Health Licensure and Certification Section

• Instructions for Completing the Initial Licensure Application
• Mental Health Initial Licensure Packet (PDF, 345 KB)
• Mental Health Licensure Change Application (PDF, 144 KB)
• Death Report Form to DHHS (PDF, 59 KB)
• N.C. Licensed Care Facilities Disaster Plan Template
  • Instructions for ISO files
  • Disaster Plan Template (ISO, 358 MB)
• Emergency relocation of clients (PDF, 105 KB)
• DHHS Incident and Death Report
  • Incident Response Improvement System (IRIS)
  • IRIS Technical Manual (PDF, 1.36 MB)
  • Incident and Death Response System Manual (PDF, 967 KB)
  • Incident and Death Report (PDF, 55 KB)

N.C. Medical Care Commission

Continuing Care Retirement Center (CCRC) Forms:

1. Construction Application -- PDF (60 KB) | Microsoft Word (DOC, 72 KB)
2. Equipment Application -- PDF (32 KB) | Microsoft Word (DOC, 64 KB)
3. Request For Disbursement -- PDF (28 KB) | Microsoft Word (DOC, 36 KB)
4. Community Benefit GS105 Form -- PDF (36 KB) | Microsoft Word (DOC, 64 KB)
5. HFA Project Funds Status Report Master -- PDF (8 KB) | Microsoft Excel (XLS, 20 KB)
6. Community Benefits Form of Agreement and Program Description -- PDF (92 KB) | Microsoft Word (DOC, 52 KB)

Hospital Forms:

1. Construction Application -- PDF (56 KB) | Microsoft Word (DOC, 108 KB)
2. Equipment Application -- PDF (32 KB) | Microsoft Word (DOC, 60 KB)
3. Community Benefits (ANDI) ** -- PDF (36 KB) | Microsoft Word (DOC, 48 KB)
4. Request For Disbursement -- PDF (28 KB) | Microsoft Word (DOC, 36 KB)
5. HFA Project Funds Status Report Master -- PDF (8 KB) | Microsoft Excel (XLS, 20 KB)

MBIA Application for 1985 Pool PDF (24 KB)| Microsoft Word (DOC, 48 KB)

Other Forms:

• Sample Accountant's Compliance Letter Format -- (PDF, 20 KB)
• Sample Compliance Checklist for Borrowers -- PDF (68 KB) | Microsoft Word (DOC, 136 KB)
• Sample Agreed Upon Procedures Forecasts Report (PDF, 240 KB)
• Sample Swap Education Certificate (PDF, 265 KB)
• Sample Borrower Swap Certification (PDF, 380 KB)
• Sample Officer's Annual Compliance Certificate (PDF, 12 KB)

Nursing Home Licensure and Certification Section

• Initial License Application (PDF, 60 KB)
• Alzheimer's Special Care Unit Required Disclosures Data Supplement (PDF, 20 KB)
• Breakdown of Room Numbers and Beds within those Rooms, DHSR-4504 (PDF, 21 KB)
• ACH Rule Choice (PDF, 59 KB)
• Long Term Care Facility Application for Medicare and Medicaid, CMS-671 (PDF, 367 KB)
• Assurance of Compliance with Title VI, HHS-690 (PDF, 7 KB)
• Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB)
• Civil Rights Information Request for Medicare Certification, OMB No. 0990-0243 (PDF, 81 KB)
  • Civil Rights Technical Assistance for Medicare Providers and Applicants
• Medicare Administrative Contractor Designation, DHSR-4501 (PDF, 45 KB)
• Medicare Enrollment Application - Institutional Providers, CMS-855A (PDF, 1.04 MB)
• Nursing Home Application - Bed Changes (PDF, 34 KB)
• Nursing Home Application - Change of Ownership (PDF, 63 KB)
• Admin-DON Change Form (DOC, 35 KB) (PDF, 13 KB)