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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

Regulation

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

expired.

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.

(PLEASE PRINT CLEARLY)

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

__________________________________________________________

City

____________________________ State

_______

Zip

___________

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

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

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