- Acute and Home Care Licensure and Certification Section
- Adult Care Licensure Section
- Complaint Intake Unit
- Health Care Personnel Registry
- Jails and Detention Section
- Medical Facilities Planning
- Mental Health Licensure and Certification Section
- NC Medical Care Commission
- Nursing Home Licensure and Certification Section
- Office of Emergency Medical Services
Acute and Home Care Licensure and Certification Section
- 2008 License Application for Home Care, Nursing Pool, and Hospice (PDF, 90 KB)
- Report of Death to DHHS form for state operated facilities, psych hospitals and psych units (PDF, 59 KB)
Adult Care Licensure Section
- Publication Request Form (PDF, 40 KB)
- Initial License Application (PDF, 87 KB)
- Adult Care Change Licensure Application (PDF, 192 KB)
- Family Care Change Licensure Application (PDF, 202 KB)
- Disclosure Requirements for Multi-Unit Assisted Housing with Services (PDF, 26 KB)
- DMA 3050R - 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, 36 KB)
- Resident Assessment Manual (PDF, 101 KB)
- Assisted Living Administrator Certification Requirements and Guidelines
- Assisted Living Administrator Certification Application (PDF, 14 KB)
- Family Care Home Administrator Qualifications Application (PDF, 43 KB)
- Administrator-In-Training (AIT) Preceptor Guidelines
- Continuing Education Course Guidelines
- Continuing Education Course Approval Form (PDF, 17 KB)
- Continuing Education Program Schedule Form (PDF, 5 KB)
- Instructions for Completing the Registration Form
- Instructions for Medication Testing
- Medication Administration Checklist and Instructions (PDF, 164 KB)
Complaint Intake Unit
- Complaint Form
- Report of Death to DHHS form for state operated facilities, psych hospitals and psych units (pdf)
- Critical Incident and Death Report Form for Community Mental Health Facilities
- Death Reporting Form for Adult Care Facilities (PDF, 36 KB)
Health Care Personnel Registry Section
- 24-Hour Initial Report (PDF, 52 KB)
- 5-Working Day Report (PDF, 68 KB)
- Application to be listed on North Carolina Nurse Aide I Registry (RNs and LPNs only) (PDF, 52 KB)
- Clinical Site Approval Request for Nurse Aide I Training Program (PDF, 20 KB)
- Faculty Approval Form (PDF, 52 KB)
- Faculty Removal Form (PDF, 32 KB)
- Name/Address Change Reporting Form (PDF, 44 KB)
- Request for Replacement (Duplicate) Renewal Form (PDF, 43 KB)
Jails and Detention Section
Medical Facilities Planning Section
- 2008 State Medical Facilities Plan order form (PDF, 14 KB)
Mental Health Licensure and Certification Section
N.C. Medical Care Commission
Continuing Care Retirement Center (CCRC) Forms:
- Construction Application -- PDF (60 KB) | Microsoft Word (DOC, 72 KB)
- Equipment Application -- PDF (32 KB) | Microsoft Word (DOC, 64 KB)
- Request For Disbursement -- PDF (28 KB) | Microsoft Word (DOC, 36 KB)
- Community Benefit GS105 Form -- PDF (36 KB) | Microsoft Word (DOC, 64 KB)
- HFA Project Funds Status Report Master -- PDF (8 KB) | Microsoft Excel (XLS, 20 KB)
- Community Benefits Form of Agreement and Program Description -- PDF (92 KB) | Microsoft Word (DOC, 52 KB)
Hospital Forms:
- Construction Application -- PDF (56 KB) | Microsoft Word (DOC, 108 KB)
- Equipment Application -- PDF (32 KB) | Microsoft Word (DOC, 60 KB)
- Community Benefits (ANDI) ** -- PDF (36 KB) | Microsoft Word (DOC, 48 KB)
- Request For Disbursement -- PDF (28 KB) | Microsoft Word (DOC, 36 KB)
- 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
- Self Survey Modules (pdf) Survey to determine quality care.