Form Dss-5272 - Facility Id Number Application Form - North Carolina Department Of Health And Human Services

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NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF SOCIAL SERVICES
Facility ID Number Application
Supervising Agency or Owner
Name: __________________________________________________________________________
Address: ________________________________________________________________________
City: _______________________________________ State: __________ Zip: _______________
Executive Director: __________________________________ Phone: _______________________
Contact Person: ____________________________________ Phone: _______________________
*Email: ______________________________________________ Fax: ______________________
* Important: Email address must be provided. All correspondence and notifications will be sent to this email address.
Facility
*Name: _________________________________________________________________________
*Address: ________________________________________________________________________
*City: ______________________ *State: _______ Zip: ____________ *County: _____________
Phone: ______________________ Medicaid Provider Number
: ___________________
(if applicable)
*Capacity: __________
Gender
M
F
Both
Age Range: ________________
:
*Level of Facility: _________
*License Date: From: ______________ To: ________________
* This information must match the attached DHSR Mental Health License.
Request
New ID Number
Renewal of ID Number ___________
Change for ID Number __________
Title IV-E Requirements
Two requirements must be met for county departments of social services to receive Title IV-E reimbursement
for room and board payments for children in group homes licensed by the Division of Health Service
Regulation. These requirements are:
•
A child must be in a licensed facility. You must attach a current DHSR license for your facility.
•
The licensing file of the group home must contain documentation that verifies that safety considerations
with respect to the staff and caretakers of the facility were addressed.
DSS-5272 (September 2010)
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