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                Get Dhsr 4204 2020-2025
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How to fill out the Dhsr 4204 online
Filling out the Dhsr 4204 form online is crucial for those seeking licensure as a home care agency, nursing pool, or hospice service in North Carolina. This guide provides clear instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the Dhsr 4204 form online
- Click the ‘Get Form’ button to access the Dhsr 4204 form online.
- Review the initial section to identify the purpose of the application. Select whether this is for an initial application, additional site, change of ownership, or name change.
- Fill in the legal identity of the applicant by providing the full legal name of the corporation, partnership, or individual responsible for the home care services.
- Enter the agency name or doing business as (D/B/A) and provide the mailing address for the agency. Ensure to include city, state, and zip code.
- Complete the agency site address with accurate details, including street, city, state, zip code, and county. If applicable, add your email address and website information.
- Provide contact information such as the telephone and fax numbers, along with the administrator or director's name and title.
- Indicate the licensure categories you are applying for by checking the relevant boxes for home care agency, nursing pool, hospice services, and companion/sitter services.
- In the scope of services section, check the boxes for each service you offer through your agency, ensuring to provide necessary details for services like home care, nursing pool, hospice, and companion services.
- Accreditation information should be filled if applicable. Attach the necessary documents as proofs, such as inspection reports from accrediting organizations.
- Fill in the ownership disclosure section according to the legal character of your organization (for-profit or not-for-profit). Provide detailed information as requested in the subsections.
- Complete any additional blocks required for proprietary ownership, partnerships, corporations, or government units as appropriate.
- Conclude by signing the application, providing your typed name and title, and dating the form.
- After filling out the form, make sure to save any changes. You can then download, print, or share the form as needed.
Start filling out the Dhsr 4204 form online today to ensure your health service is properly licensed.
To file a complaint against the Department of Social Services in NC, begin by documenting your concerns clearly. You should reference any relevant details related to your case, including those governed by Dhsr 4204. Submit your written complaint through the proper channels provided by the department, or utilize resources like uslegalforms for additional guidance.
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