Get Nursing Home Application Form

The Nursing Home Application Form is a vital document used for the registration renewal of facilities under the North Carolina Controlled Substances Act. This guide will provide you with a clear, step-by-step approach to filling out the form electronically, ensuring that all required information is accurately submitted.

Follow the steps to successfully complete your online application.

1. Click ‘Get Form’ button to acquire the application and open it in the designated editor.
2. Fill in all fields of Section A—Registrant Information. Ensure you provide the facility name, NC DHHS Registration number, complete address, phone number, and the name and title of the administrator.
3. In Section C, provide up to three points of contact. List their names, titles, email addresses, and phone numbers in order of preference for contact by a Drug Control Inspector.
4. In Section F, list the pharmacist consultant's name, address, and phone number along with the hours they will be present at the facility each month.
5. Section H requires a description of the storage and security measures for controlled substances at the facility. Detail locations, types of storage equipment, and access controls.
6. Review all entered information for accuracy. When complete, save your changes. You can then download, print, or share the form as needed.

Complete your Nursing Home Application Form online to ensure compliance and continued operation of your facility.