Get Nc Dhhs/dhsr/mhl5001 2013
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How to fill out the NC DHHS/DHSR/MHL5001 online
Filling out the NC DHHS/DHSR/MHL5001 form is an essential step in applying for a license to operate a mental health facility in North Carolina. This guide provides a clear, step-by-step approach to ensure that users can navigate the online form with ease and confidence.
Follow the steps to successfully complete the NC DHHS/DHSR/MHL5001 form.
- Click ‘Get Form’ button to access the online version of the NC DHHS/DHSR/MHL5001 form and open it in your preferred editor.
- Complete the facility name section, ensuring you input the official name as it will appear on your license. This name should be used in all correspondence related to your application.
- Provide the facility site address. This needs to be a physical address; P.O. boxes are not acceptable. Ensure to include the city, state, and zip code.
- Fill out the correspondence mailing address where all communication will be sent, including an email address for electronic correspondence.
- Enter the name of the facility director and the name of the main contact person, including their positions and contact details.
- The facility licensee or an individual with signatory authority must provide their name and signature on the form, along with the date of signing.
- Detail the management company information if the facility is managed by a separate entity. Provide the name, contact person, and address of the company.
- Include the National Provider Identifier (NPI) if applicable. This is necessary for health care providers seeking licensure.
- Indicate the legal identity of the licensee, providing the full legal name and type of entity (e.g., corporation, partnership). Include the owner details and their business address.
- List all owners, principles, affiliates, or shareholders holding a 5% or more interest in the facility. Include their names, social security numbers, and addresses.
- Select the service categories for which the facility is applying for licensure. Complete the table by indicating the number of beds assigned for different age groups.
- Complete the physical plant section, providing the names of local officials for zoning, building, fire safety, and sanitation inspections.
- Attach the required photographs of the facility as specified in the guidelines. Ensure they are properly labeled.
- Once all sections are completed, review the application for accuracy and completeness before submission. Incomplete applications may delay the licensing process.
- Submit the application by mailing it to the Department of Health and Human Services at the designated address, ensuring it includes all required documents and original signatures.
Get started on your application now by completing the NC DHHS/DHSR/MHL5001 form online.
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The three main divisions of the North Carolina Department of Health and Human Services (NCDHHS) are the Division of Social Services, the Division of Public Health, and the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. Each division focuses on critical areas of public health and support. Together, they implement and manage programs to enhance the well-being of residents, in line with the principles set by NC DHHS/DHSR/MHL5001.
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