Form Dss-5272 - Facility Id Number Application Form - North Carolina Department Of Health And Human Services Page 2
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2The Executive Director of the Facility or his/her designee must answer the following question:
Has this facility been in continuous compliance with 10A NCAC 27G .0202* and GS 122C-80**?
Yes
No
*10A NCAC 27G .0202 PERSONNEL REQUIREMENTS
(b) All facilities shall ensure that the director, each staff member or any other person who provides care or services to
clients on behalf of the facility:
(4) has no substantiated findings of abuse or neglect listed on the North Carolina Health Care Personnel Registry.
(c) All facilities or services shall require that all applicants for employment disclose any criminal conviction. The impact of
this information on a decision regarding employment shall be based upon the offense in relation to the job for which the
applicant is applying.
•
The licensing file must contain documentation that it is in compliance with GS 122C-80 (Criminal history record
check required for certain applicants for employment).
**GS 122C-80:
________________________________________________
____________________
Signature of Executive Director of the Facility or Designee
Date
Submit completed application to:
North Carolina Division of Social Services
Regulatory and Licensing Services
952 Old US Highway 70
Black Mountain, North Carolina 28711
Attn: Cindy Norton
Phone: 828.669.3388
Fax: 828.669.3365
Attach copy of DHSR Mental Health License
Note: The approval and assignment of a Facility ID Number is only available for Mental Health Residential
Treatment Facilities for children and adolescents licensed by the North Carolina Division of Health Service
Regulation (DHSR). Upon submission of this completed application, please allow 20 working days for review
and approval. If DHSR licensure allows, the effective dates for the Facility ID Number will be from the current
month of service until the DHSR license expiration date. Please be aware that the Facility ID Number will
expire on the same day as the DHSR license, therefore the Facility ID Number must also be renewed when the
DHSR license is renewed. Be sure to inform the County Department of Social Services of the Facility ID
Number as soon as you receive it. To request an electronic version of this Facility ID Number application,
please email Cindy.Norton@dhhs.nc.gov.
DSS-5272 (September 2010)
Page 2 of 2
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