Get Nc Dhhs 4103 2017-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the NC DHHS 4103 online
Filling out the NC DHHS 4103 form is an essential step for individuals seeking family planning services through the North Carolina Department of Health and Human Services. This guide provides clear, step-by-step instructions to help users navigate the online form effectively.
Follow the steps to complete the NC DHHS 4103 form
- Click the ‘Get Form’ button to obtain the NC DHHS 4103 form and open it in the online editor.
- Enter your last name in the designated field, followed by your first name and middle initial (if applicable).
- In the patient number section, provide your unique patient identification number if you have one.
- Input your date of birth in the format MM/DD/YYYY, ensuring to select the correct month, day, and year.
- Select your race from the available options by checking the appropriate box. Options include American Indian or Alaska Native, Asian, Black/African American, Native Hawaiian/Other Pacific Islander, Unknown, and White.
- Indicate your ethnic origin by checking the box that best describes your background, such as Hispanic Cuban, Hispanic Mexican American, etc.
- Choose your gender by marking the box for Female or Male.
- Provide your county of residence by selecting the relevant option from the dropdown menu.
- Read through the voluntary participation and confidentiality statement, ensuring you understand the information provided regarding Title X services.
- Review the listed benefits, risks, and possible side effects of the Copper IUD method to be fully informed.
- Consent to the statements regarding the use of the Copper IUD by signing and dating the form at the designated section.
- If applicable, have an interpreter fill out the interpreter’s statement, providing their translation details and signature.
- After completing all sections, ensure to save your changes, download, or print the form as needed.
Complete your documents online to start your family planning journey today.
The current Secretary of NCDHHS is responsible for overseeing the direction and management of the department's operations in North Carolina. Appointed by the governor, the Secretary plays a crucial role in creating policies that support health and human services. By following the Secretary's announcements and directions, you can better understand the strategic initiatives within NC DHHS 4103. This awareness can guide you in accessing available resources and support.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.