Registration and Inventory Forms

The 2014 Equipment Registration and Inventory Data Collection forms are available for download. These are the forms on which to report information related to the legally required "Registration and Inventory of Medical Equipment" (G.S. § 131E-177). On these forms, owners and providers certify that they owned, leased, or operated equipment cited in G.S. § 131E-176 and utilized this equipment in performing services at specific sites in North Carolina.

Please download the appropriate form(s) for your facility, complete all sections and return to the Medical Facilities Planning Branch by Friday, January 31, 2014.

  1. Complete and sign the form
  2. Return the form by one of two methods:
    1. Email a scanned copy to DHSR.SMFP.Registration-Inventory@dhhs.nc.gov
    2. Mail the form to Kelli Fisk, Medical Facilities Planning Branch, 2714 Mail Service Center, Raleigh, N.C. 27699-2714

Note: Fixed equipment operated in a facility licensed under a hospital should be reported on that hospital’s license renewal application, and not duplicated on this form.

If you have questions, call Kelli Fisk in the Medical Facilities Planning Branch at 919-855-3865 or email DHSR.SMFP.Registration-Inventory@dhhs.nc.gov.

Forms