Get Nc Dhsr-4204 2019-2026

The NC DHSR-4204 form is essential for individuals or organizations seeking licensure for home care, nursing pool, and hospice services in North Carolina. This guide will provide you with a clear set of instructions on how to accurately complete this important document online.

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

1. Use the ‘Get Form’ button to access the NC DHSR-4204 and open it in your online editor.
2. Begin by identifying the legal identity of the applicant. Enter the full legal name of the corporation, partnership, individual, or other legal entity owning the services.
3. Complete the agency name or doing business as (D/B/A) field with the primary name under which your facility or services are advertised.
4. Provide the agency mailing address, indicating if materials are to be sent to another address.
5. Fill in the agency site address with the physical location where the services will be offered.
6. Include the email address and website URL if applicable. Enter the contact telephone number and fax number.
7. Identify the administrator or director of the agency, including their title.
8. In the licensure categories applied for section, check all relevant boxes for home care agency, nursing pool, and hospice services.
9. Check each service offered through your site in the scope of services section. Ensure to clarify if you also hold a medical equipment permit if applicable.
10. If applicable, complete the accreditation information section by indicating your accrediting organization and expiry date.
11. For home care agency applicants, include your Medicare provider number. Specify if your agency is a parent, branch, or sub-unit.
12. For hospice applicants, provide your hospice provider number and state if a Certificate of Need has been issued for your services.
13. Nursing pool applicants must attach necessary documentation including personnel policies and insurance policies.
14. Fill in ownership disclosure, detailing the legal ownership character, and provide the required contact information related to the ownership.
15. If part of a multiple facility agency system, indicate whether your agency is part of it and list the names and licenses of other entities.
16. Review your completed form for accuracy, and ensure all sections and attachments are filled out correctly.
17. Save your changes, then download or print the completed form for your records.
18. Share the completed form as required or submit it through the designated channels.

Start completing the NC DHSR-4204 online today to ensure a smooth application process.