NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF SOCIAL SERVICES
Facility ID Number Application
Supervising Agency or Owner
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.
*City: ______________________ *State: _______ Zip: ____________ *County: _____________
Phone: ______________________ Medicaid Provider Number
Age Range: ________________
*Level of Facility: _________
*License Date: From: ______________ To: ________________
* This information must match the attached DHSR Mental Health License.
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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