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)
• Initial License Application for Overnight Respite Services (PDF, 70 KB)
• Disclosure Requirements for Multi-Unit Assisted Housing with Services and Annual Registration (PDF, 26 KB)
• Submission of Training for Penalty Recommendation (PDF, 21 KB)
• Medication Release Form for Resident Leave of Absence (PDF, 34 KB)
• N.C. Licensed Care Facilities Disaster Plan Portal
  • You must have an NCID account to access the portal. you can register for a free NCID account online.

  Complaint Intake and Health Care Personnel Investigations Section

  • 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)
  • Initial Allegation Report Form/Investigation Report Form (XLSX, 130 KB)
  • Initial Allegation Report Instructions (PDF, 226 KB)
  • Investigation Report Instructions (PDF, 386 KB)
  • Frequently Asked Questions - Reporting Requirements and Forms (PDF, 302 KB)

  Construction Section

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

  Health Care Personnel Education and Credentialing Section

  • 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)

  Healthcare Planning and Certificate of Need Section

  • End-Stage Renal Disease Data Collection Form
  • Progress Report 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 Portal
    • You must have an NCID account to access the portal. you can register for a free NCID account online.
    • 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)
    • Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB)
    • Civil Rights Information Request for Medicare Certification, OMB No. 0945-0006 (PDF, 81 KB)
      • Civil Rights Technical Assistance for Medicare Providers and Applicants

      Office of Emergency Medical Services

      • Volunteer Health Services Act
      • Application to Provide Health Care Services [DOC, 31 KB] [PDF, 41 KB]
      • Notice of Voluntary Health Care Services [DOC, 30 KB] [PDF, 53 KB]
      • Paramedic Vehicle Inspection Report (PDF, 208 KB)
      • Advanced Emergency Medical Technician (AEMT) Vehicle Inspection Report (PDF, 220 KB)
      • Emergency Medical Technician (EMT) Vehicle Inspection Report (PDF, 189 KB)
      • Non-Transport Vehicle Inspection Report - Paramedic (PDF, 298 KB)
      • Non-Transport Vehicle Inspection Report- AEMT (PDF, 315 KB)
      • Ambulance Bus Vehicle Inspection Report (PDF, 44 KB)
      • Convalescent Vehicle Inspection Report (PDF, 70 KB)
      • Water Vehicle Inspection Report (PDF, 77 KB)
      • AED Placement Notification for EMS (PDF, 172 KB)
      • N.C. form for Certification of Training for the Use of Epinephrine (PDF, 30 KB)
      • DNR & MOST Order Form

      This page was last modified on December 17, 2020.