Get Nc Dhsr-4204 2023-2025

This guide provides clear instructions on how to complete the NC DHSR-4204 form online for licensure of home care, nursing pool, and hospice services in North Carolina. Whether you are an experienced user or new to digital document management, this comprehensive guide will help you navigate each section with ease.

Follow the steps to effectively fill out the NC DHSR-4204 online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by indicating the purpose of your application by selecting one of the options: Initial, Change of Ownership (CHOW), or Name Change.
3. Enter the legal identity of the applicant, including the full legal name of the corporation, partnership, or individual.
4. Provide your agency's name or doing business as (D/B/A) and the mailing address relevant to your agency.
5. Fill out the agency site address, ensuring to include street, city, state, zip code, and county.
6. List your contact information including email address, website (if applicable), telephone number, and fax number.
7. Specify the administrator or director's name and title to associate with the application.
8. Select the licensure categories you are applying for by checking all that apply: Home Care Agency, Nursing Pool, or Hospice Services.
9. In the scope of services, check each service offered through your agency, indicating whether you hold a medical equipment permit and providing details as requested.
10. Fill out accreditation information, sharing details about the accrediting organization if applicable.
11. Complete ownership disclosure, marking the applicable ownership type and providing necessary details about the owner.
12. If applicable, provide information about multiple facility agency systems and any contractual relations with other agencies.
13. Finally, certify that all information provided is accurate by signing and entering your typed name, title, and date.
14. Once you have completed the form, you may save changes, download, print, or share the form as needed.

Complete your NC DHSR-4204 form online today for efficient licensure processing.