Forms and Applications
The following applications and forms are for use by nursing home facilities and those seeking an initial license.
Change of Ownership (CHOW)
- Nursing Home Application - Change of Ownership (PDF, 63 KB)
- Alzheimer's Special Care Unit Required Disclosures Data Supplement (PDF, 20 KB)
- Long Term Care Facility Application for Medicare and Medicaid, CMS-671 (PDF, 367 KB)
- Breakdown of Room Numbers and Beds Within Those Rooms, DHSR-4504 (PDF, 14 KB)
- Assurance of Compliance with Title VI, HHS-690 (PDF, 7 KB)
- Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB)
- Civil Rights Information Request for Medicare Certification, OMB No. 0990-0243 (PDF, 81 KB)
- Medicare Administrative Contractor (PDF, 28 KB)
- Medicare Administrative Contractor Designation, DHSR-4501 (PDF, 9 KB)
- Medicare Enrollment Application - Institutional Providers, CMS-855A (PDF, 1.04 MB)
- ACH Rule Choice (PDF, 59 KB)
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.
- Admin-DON Change Form (DOC, 35 KB) (PDF, 13 KB)
Links to Other Government Forms
