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PRINTED: 05/04/2016 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION A.
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01
To fill out the NC DHSR AHCLCS statement, follow these steps:
02
Begin by providing the necessary personal information, such as your name, address, and contact details.
03
Identify the type of facility or service you are applying for by selecting the appropriate option from the provided list.
04
Fill in the required information regarding the facility or service, such as its location, capacity, and any relevant certifications.
05
Provide details about your experience in the field, including any licenses or certifications you hold.
06
Answer the questions related to your compliance with state regulations and any previous violations or penalties.
07
Attach any supporting documents or additional information requested by the form.
08
Review the completed statement for accuracy and make any necessary corrections or additions.
09
Sign and date the statement to certify that the information provided is true and accurate.
10
Submit the filled-out AHCLCS statement to the appropriate NC DHSR office as instructed.

Who needs nc dhsr ahclcs statement?

01
The NC DHSR AHCLCS statement is needed by individuals or organizations who are applying for a license, certification, or registration for a healthcare facility or service in North Carolina. This may include, but is not limited to, hospitals, nursing homes, home health agencies, hospices, adult care homes, and mental health facilities. The statement helps the Department of Health and Human Services assess the qualifications and compliance of applicants with state regulations to ensure the provision of safe and quality healthcare services.
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The North Carolina Department of Health Service Regulation (DHSR) Annual Home Care and Licensure Certification Statement is a required document for licensed home care providers.
All licensed home care providers in North Carolina are required to file the DHSR Annual Home Care and Licensure Certification Statement.
The NC DHSR AHCLCS statement can be filled out online on the DHSR website or submitted by mail with the required information and documentation.
The purpose of the DHSR AHCLCS statement is to ensure that licensed home care providers are in compliance with state regulations and to report important information about their services.
The NC DHSR AHCLCS statement requires information such as provider demographics, license information, services provided, staffing information, and quality measures.
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