Get Nursing Home Application

Filling out the Nursing Home Application online can seem daunting, but with careful attention to detail, you can successfully complete the form. This guide provides clear, step-by-step instructions to ensure your application is thorough and accurate.

Follow the steps to complete your application accurately.

1. Click ‘Get Form’ button to access the Nursing Home Application. This will allow you to open the document in an editable format.
2. Begin by reviewing the Application Instructions. Ensure that you read through the requirements carefully before filling out any information.
3. In Section A, gather the registrant information including Facility Name, NC DHHS Registration #, Facility's Address, County, State, City, Zip, Phone Number, Mailing Address, Number of Beds, and the Administrator's Name and Title. Fill out this section fully, avoiding any blank fields.
4. Proceed to Section B for Registration Classification. Check all applicable drug schedules that apply to your application. Answer the questions regarding current authorization and any felony convictions truthfully.
5. In Section C, list up to three contacts who are knowledgeable about controlled substances at your facility. Provide their names, titles, email addresses, and phone numbers.
6. Complete Section D by providing the date of the most recent NC DHHS Registration and check all relevant events that have occurred since that date. Note that if applicable events are checked, you will need to apply for a new registration instead.
7. If applicable, fill in Section E with information about your pharmacy supplier, or mark N/A if your registrant owns its own pharmacy.
8. In Section F, provide the name and contact details of the Pharmacist Consultant. If not applicable, fill in with N/A.
9. For Section G, address questions regarding the controlled substance inventory and the Emergency Kit. Provide accurate information regarding your inventory, ownership, DEA registration, and compliance.
10. Continue with Section H to describe the storage and security measures for controlled substances and who has access to these locations.
11. Section I requires you to delineate the procedures for purchasing, receiving, and dispensing controlled substances. Include all necessary record-keeping protocols.
12. Lastly, in Section J, outline any additional measures taken to prevent the diversion of controlled substances.
13. After completing the form, review all your entered information for accuracy. Save your changes, download, and print the application. Once finalized, email the completed document along with necessary signed copies to the designated address.

Complete your Nursing Home Application online today for a smoother registration process.