Form Dhsr/hcpr 4503 - Name/address Change Reporting Form - N.c. Department Of Health And Human Services

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2709 Mail Service Center
Phone: 919-855-3969
Raleigh, NC 27699-2709
Fax: 919-733-9764
Center for Aide Regulation and Education Branch
Division of Health Service
N.C. Health Care Personnel Registry Section
N.C. Department of Health
Regulation
and Human Services
Name/Address Change Reporting Form
Nurse Aide I / Medication Aide / Geriatric Aide
To report your address or name change to the N.C. Nurse Aide I Registry, the N.C. Medication Aide Registry,
or the N.C. Geriatric Aide Registry, please complete all fields below. Sign in the space provided and fax or
mail the form with copies of legal documents, if required, to the fax number or address below.
Fax:
(919) 733-9764
U.S. Mail: Center for Aide Regulation and Education
2709 Mail Service Center
Raleigh, NC 27699-2709
Type or Print Clearly
Aide Name as it Appears on Registry
_____________________________________________________
Last 4 Digits of Your Social Security Number
_______________________________________________
Your Nurse Aide I Listing Number (if applicable)
_____________________________________________
Date of Birth (Month/Day/Year)
__________________________________________________________
New Address
Street or PO Box
_____________________________________________________________________
City
__________________ State
Zip
_______________________________________
Home Telephone Number with Area Code
_________________________________________________
Work Telephone Number with Area Code
__________________________________________________
Email Address
_______________________________________________________________________
New Full Name (Proof Required*)
______________________________________________________
Aide Signature
______________________________________________________________________
*Required Proof of Name Change
If reporting a name change, please provide copies only - not originals - of 1) your new, signed social security
card with the new name on it and 2) the legal document (such as the court-issued marriage certificate, divorce
decree, or legal resumption of prior name document) that clearly demonstrates the name change. A driver’s
license copy is NOT acceptable.
DHSR/HCPR 4503 (Rev. 03/09) NCDHHS

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