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NC Division of Health Service Regulation

Acute and Home Care Licensure and Certification Section

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Forms and Applications

The following applications and forms are for use by appropriate staff at acute care facilities and home care agencies.

• 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, 40 KB)
• Hospital restraint death reporting to CMS (PDF, 523 KB)
  • The Centers for Medicare and Medicaid Services has developed a dedicated email address, [email protected], for submitting death reports for hospitals.

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This page was last modified on October 14, 2011.

Division of Health Service Regulation