NC DHSR Form 4504 2009-2025 free printable template

BREAKDOWN OF ROOM NUMBERS AND BEDS WITHIN THOSE ROOMS NAME OF FACILITY: PROVIDER TOWN: NUMBER: If change in beds or room numbers the effective date of the change: CHECK ONLY ONE Room Number # of Beds

How to fill out nc dhsr bed breakdown

How to fill out NC DHSR Form 4504

1. Obtain a copy of the NC DHSR Form 4504 from the official website or local office.
2. Read the instructions carefully to understand the requirements.
3. Fill out the personal information section, including your name, address, and contact information.
4. Complete the section regarding the type of service being requested.
5. Provide details about the facility or service being reported.
6. List the specific issues or complaints you are addressing in the form.
7. Attach any additional documentation or evidence that supports your claims.
8. Review the completed form for accuracy and completeness.
9. Sign and date the form before submission.
10. Submit the form to the appropriate NC DHSR office via mail or electronically as per instructions.

Who needs NC DHSR Form 4504?

1. Individuals or entities wishing to report issues related to health care facilities in North Carolina.
2. Patients or family members of patients who have experienced problems with care services.
3. Healthcare providers needing to report incidents or compliance issues.
4. Advocacy groups focusing on health care services and patient rights.

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What is NC DHSR Form 4504?

NC DHSR Form 4504 is a reporting form used in North Carolina for the purpose of documenting certain health care-related information required by the Division of Health Service Regulation.

Who is required to file NC DHSR Form 4504?

Health care providers and facilities in North Carolina that are subject to specific regulations under the Division of Health Service Regulation are required to file NC DHSR Form 4504.

How to fill out NC DHSR Form 4504?

To fill out NC DHSR Form 4504, applicants should gather the necessary information, follow the instructions provided on the form, complete all required sections, and submit it to the appropriate division.

What is the purpose of NC DHSR Form 4504?

The purpose of NC DHSR Form 4504 is to ensure compliance with state regulations regarding health care services and to collect important data for regulatory and oversight purposes.

What information must be reported on NC DHSR Form 4504?

NC DHSR Form 4504 requires reporting information such as facility details, personnel data, service types offered, and other relevant operational information as mandated by the Division of Health Service Regulation.