Request For Replacement (Duplicate) Renewal Form - N.c. Department Of Health And Human Services


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. Department of Health
N.C. Health Care Personnel Registry Section
and Human Services
Request for Replacement (Duplicate) Renewal Form
N.C. Nurse Aide I / N.C. Medication Aide
Aides automatically receive a renewal application about three months before the listing expires if their listings
are in good standing and their addresses are up to date with the registry. It is not necessary to contact the
registry to receive the automatic mailing.
If your form was lost, damaged, or you missed the automatic mailing, please return this completed form to the
registry. A replacement form will be issued and returned to you by mail.
Replacement forms will only be issued if your listing is due to expire in the next 3 months or has already
For help, contact registry staff at 919-855-3969, weekdays, from 8 a.m. to 12 noon, and from 1 p.m. to 3 p.m.
Complete all information below. Incomplete or unsigned requests cannot be processed and will not
receive a response.
1. Aide Name as it Appears on Registry
2. Last 4 Digits of Your Social Security Number
3. Your Nurse Aide I Listing Number (if applicable)
4. Date of Birth (Month/Day/Year)
5. Street Address/PO Box
____________________________ State
6. Home Phone Including Area Code
7. Work Phone Including Area Code
8. Email Address
9. Aide’s Signature_____________________________________________________________________
Check here if this is a new mailing address. (No additional change of address form is needed.)
Mail or Fax this form to:
Center for Aide Regulation and Education
2709 Mail Service Center
Raleigh, NC 27699-2709
Fax: (919) 733-9764
DHSR/HCPR 4504 (Rev. 06/11) NCDHHS


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal