NC DHSR/HCPR Form 4500 2014-2025 free printable template

N.C. Department of Health Human Services FAX 919 733-3207 Phone 919 855-3968 Health Care Personnel Registry 5-WORKING DAY REPORT Division of Health Service Regulation 2719 Mail Service Center Raleigh NC 27699-2719 Investigation Report from Facility/Provider 24-Hour Initial report sent to HCPR Yes No The results of all investigations must be reported within 5-working days of the initial notification. see NC Gen. Stat. 131E-256 g Provider Information Date submitted Via FAX Mail IRIS Other...

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How to fill out NC DHSR/HCPR Form 4500

1. Obtain the NC DHSR/HCPR Form 4500 from the official website or local office.
2. Fill out the applicant's information at the top of the form, including name, address, and contact details.
3. Provide details of the facility or service being requested, including name and address.
4. Indicate the type of application (initial, renewal, etc.) in the designated section.
5. Complete the 'Ownership Information' section by listing all owners and their details.
6. Answer the questions in the 'Program/Service Information' section accurately.
7. Attach any required supporting documentation, such as licenses or certifications.
8. Review the form for completeness and accuracy, ensuring all required fields are filled.
9. Sign and date the form to certify that the information provided is true and correct.
10. Submit the completed form to the appropriate address provided in the instructions.

Who needs NC DHSR/HCPR Form 4500?

1. Healthcare providers applying for licensure or certification.
2. Facilities seeking to renew their existing licenses.
3. Organizations planning to offer new healthcare services in North Carolina.
4. Individuals or entities looking to establish a healthcare facility.

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How to report an illegal activity in the healthcare setting in NC?

To report private insurance fraud, contact the NC Department of Insurance or call the department at (888) 680-7684. To report fraud and abuse in state licensed facilities, agencies and nursing homes, contact the North Carolina Division of Health Service Regulation.

How do I report a CNA in NC?

Certified Nursing Assistants or Nurse Aides - Refer Complaints to: Division of Health Service Regulation or 1 (800) 624-3004. Complaints Against a Facility - Refer Complaints to: Division of Health Service Regulation or1 (800) 624-3004.

Who investigates nursing homes in NC?

You may also report your complaint to the North Carolina Long Term Care Ombudsman Program. This office investigates and attempts to resolve the concerns or complaints of nursing home residents and families.

How do I report nursing home neglect in NC?

Reporting Nursing Home Abuse in North Carolina Contact the facility's administrator and file a formal complaint. Call your county's Department of Social Services (more specifically, the Adult Protective Services. File a complaint with the North Carolina Long Term Care Ombudsman Program.

Who do you report nursing homes to in North Carolina?

The NC DHHS Division of Health Service Regulation It handles complaints and investigations related to issues like: nursing homes; adult care homes; hospitals; home care, home health, or hospice agencies; and mental health group homes and other 24-hour facilities.

How do I complain about Medicaid in NC?

You can call us at 877-201-3750 from 8 a.m. to 5 p.m., every Monday through Friday except for State holidays.

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What is NC DHSR/HCPR Form 4500?

NC DHSR/HCPR Form 4500 is a form used in North Carolina for reporting certain data related to health care provider services and facilities, particularly in the context of health care regulation.

Who is required to file NC DHSR/HCPR Form 4500?

Health care providers and facilities in North Carolina that are subject to state regulations and requirements concerning data reporting must file NC DHSR/HCPR Form 4500.

How to fill out NC DHSR/HCPR Form 4500?

To fill out NC DHSR/HCPR Form 4500, providers must complete all sections of the form as instructed, including entering accurate information regarding services rendered, patient counts, and other relevant metrics as required by the guidelines provided.

What is the purpose of NC DHSR/HCPR Form 4500?

The purpose of NC DHSR/HCPR Form 4500 is to collect data for monitoring, regulation, and planning purposes in the health care sector, ensuring compliance with state health care laws and strategies.

What information must be reported on NC DHSR/HCPR Form 4500?

The information that must be reported on NC DHSR/HCPR Form 4500 includes details such as patient demographics, service types, volumes, and other operational data as specified in the form instructions.