Nursing Home Application Form - Bed Changes - North Carolina Department Of Health And Human Services - 2016
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2NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF HEALTH SERVICE REGULATION
NURSING HOME LICENSURE AND CERTIFICATION SECTION
FOR OFFICIAL USE ONLY
2711 MAIL SERVICE CENTER
Computer Number
RALEIGH, NORTH CAROLINA 27699-2711
Bed Change ___________________
TELEPHONE: (919) 855-4520
Effective Date __________________
Fee Received ___________________
Check No: _____________________
Amount: _______________________
2016
NURSING HOME APPLICATION – BED CHANGES
(Including Adult Care Home Beds in Combination Facilities)
LEGAL IDENTITY OF APPLICANT:
_____________________________________________________________________________________________________
{Full legal name of corporation, partnership, individual, or other legal entity owning the enterprise or service.}
DOING BUSINESS AS (d/b/a) - names under which the facility or services are advertised or presented to the public:
PRIMARY: _____________________________________________________________________________________
Other: _________________________________________________________________________________________
If the above names are NOT IDENTICAL to the names on the current license, please check reason for the change:
___ Change of Ownership/Licensee
Facility Name Change
___ Other (Specify): ______________________________________________________________________________
NORTH CAROLINA LICENSE NUMBER: ___________________
FACILITY MAILING ADDRESS:
Street/P O Box: ________________________________________________________________________________________
City: __________________________________________________ State: ________________ Zip: _________-________
(Ex. 27626 - 0530)
FACILITY SITE:
Street: _______________________________________________________________________________________________
City: ___________________________________________
County:__________________________________________
Telephone: (____)_____________________________________________________________________________________
Fax:
(____)_________________________________________________________________________________ _____
PATIENT SERVICES
1.
Is the facility now to be a “Combination Facility”, thereby incorporating licensed ACH beds?
1. YES ___ NO ___
If “Yes”, indicate which rules the facility chooses to apply to the operation of
these ACH beds.
Nursing Home Licensure _____ ACH Licensure___
(
Complete checklist if using both sets of rules.)
DHHS/DHSR/NHL #7004 (Rev. 12/2015)
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