Forms and Applications

The following applications and forms are for use by nursing homes and those seeking an initial license.

Nursing Home Application

Change of Ownership (CHOW)

Bed Breakdown

These are the forms needed for making a change to the number of certified beds in a nursing facility.

Administrator and Director of Nursing Change

Nursing homes are required to notify the Nursing Home Licensure and Certification Section within one working day following the occurrence of change in administrator or director of nursing. Please submit the completed Admin-DON Change form to DHSR.NH.ADMandDON.CHANGES@dhhs.nc.gov.

Application for Civil Money Penalty Funds

Effective January 1, 2012, the Centers for Medicare and Medicaid Services has established a process for any entity to apply for funding to improve resident outcomes in certified nursing homes. Only civil money penalty (CMP) fund applications that meet the statutory intent of the regulations, Federal law and policy will be considered. Complete the application for consideration. Please direct any questions to Beverly.Speroff@dhhs.nc.gov or Becky.Wertz@dhhs.nc.gov. You may submit a completed application to Beverly.Speroff@dhhs.nc.gov or Becky.Wertz@dhhs.nc.gov.

Links to Other Government Forms