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PRINTED: 08/15/2018 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:(X3) DATE SURVEY COMPLETED 06/27/2018STREET

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How to fill out nc dhsr aclsl statement

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Step 1: Download the NC DHSR ACLSL statement form from the official website

02

Step 2: Fill in the personal information section, including your name, address, and contact details

03

Step 3: Provide information about the facility or organization you are associated with

04

Step 4: Answer the questions about your criminal history, including any convictions or pending charges

05

Step 5: Sign and date the form before submitting it to the appropriate authority

Who needs nc dhsr aclsl statement?

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Anyone working in a healthcare facility or organization in North Carolina may need to fill out the NC DHSR ACLSL statement

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What is nc dhsr aclsl statement?

The nc dhsr aclsl statement is a form issued by the North Carolina Department of Health Service Regulation (DHSR) for the reporting of financial information related to adult care homes.

Who is required to file nc dhsr aclsl statement?

All adult care homes in North Carolina are required to file nc dhsr aclsl statement.

How to fill out nc dhsr aclsl statement?

The nc dhsr aclsl statement can be filled out online on the DHSR website or submitted by mail with the required financial information.

What is the purpose of nc dhsr aclsl statement?

The purpose of the nc dhsr aclsl statement is to monitor the financial health and stability of adult care homes in North Carolina.

What information must be reported on nc dhsr aclsl statement?

The nc dhsr aclsl statement requires reporting of revenue, expenses, and other financial data related to the operation of the adult care home.

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