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PRINTED: 11/20/2018 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X3) DATE SURVEY COMPLETED10/09/2018STREET

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01

To fill out the NC DHSR MHLCS statement, follow these steps:

02

Start by providing your personal information, such as your full name, address, and contact details.

03

Indicate whether you are applying as an individual or on behalf of an organization.

04

Specify the date of the incident or event that the statement is related to.

05

Include a detailed description of the incident or event, including any relevant dates, times, and locations.

06

Provide names and contact information of any witnesses or individuals involved in the incident.

07

Describe any injuries, damages, or consequences resulting from the incident.

08

Indicate whether any legal action has been taken or is planned regarding the incident.

09

Sign and date the statement to confirm its accuracy and completeness.

Who needs nc dhsr mhlcs statement?

01

The NC DHSR MHLCS statement may be needed by individuals or organizations who have experienced or witnessed incidents related to mental health, developmental disabilities, or substance abuse services in North Carolina.

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What is nc dhsr mhlcs statement?

The NC DHSR MH/LCS statement is a form required to be filed by certain mental health and substance abuse facilities in North Carolina.

Who is required to file nc dhsr mhlcs statement?

Mental health and substance abuse facilities in North Carolina are required to file the NC DHSR MH/LCS statement.

How to fill out nc dhsr mhlcs statement?

The NC DHSR MH/LCS statement can be filled out online through the designated portal provided by the Department of Health Service Regulation.

What is the purpose of nc dhsr mhlcs statement?

The purpose of the NC DHSR MH/LCS statement is to report essential information about the mental health and substance abuse services provided by facilities in North Carolina.

What information must be reported on nc dhsr mhlcs statement?

The NC DHSR MH/LCS statement requires facilities to report data on the types of services offered, number of clients served, staffing information, and financial details.

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