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The document is an application form from the North Carolina Department of Health and Human Services for obtaining or renewing a Facility ID Number for mental health residential treatment facilities for children and adolescents. It outlines the necessary information required from the facility, including contact details, licensing compliance, and Title IV-E reimbursement requirements. The form must be submitted to the Division of Social Services along with a current DHSR license, and it emphasizes the importance of compliance with personnel requirements and criminal history checks.

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