Online forms are available from various sections of the Division of Health Service Regulation.
Acute and Home Care Licensure and Certification Section
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
- DMA 3050 - 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, 144 KB)
- Family Care Home Administrator Qualifications Application (PDF, 43 KB)
- 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)
- Facility Medication Aide Verification (PDF, 389 KB)
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)
Health Care Personnel Education and Credentialing Section
Healthcare Planning and Certificate of Need Section
Mental Health Licensure and Certification Section
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)
- 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)
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
