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Dhsrhcpr from 4501 2011 form

Dhsrhcpr from 4501 2011 form-2025

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163 votes

The document outlines the procedures for reporting allegations against health care personnel in North Carolina, specifically focusing on incidents of resident abuse or neglect. It mandates that all such allegations must be reported to the Health Care Personnel Registry (HCPR) within 24 hours, with specific timelines for reporting crimes resulting in serious bodily injury. The document includes sections for provider and resident information, details of the incident, and requirements for follow-up investigations.

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Click ‘Get Form’ to open the dhsrhcpr from 4501 2011 form in our platform.
Begin by filling out the Provider Information section. Enter the Facility/Provider Type, County, and Facility/Provider Name along with the License and National Provider numbers.
Next, provide contact details including the Main Office Phone number, Fax number, Email address, and Mailing Address. Ensure all fields are accurately completed.
In the Allegation/Incident Type section, check all applicable boxes related to the incident. If there is reasonable suspicion of a crime, explain it in the Allegation/Incident Details area.
Fill in the Incident Date and Time, followed by a detailed description of any physical or mental injury/harm sustained by the resident.
Complete the Resident Information and Accused Individual Information sections with full names, dates of birth, job titles, and contact information as required.
Finally, ensure that you sign and date the report before submitting it through our editor for efficient processing.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (375 Votes)
2011	4.4 Satisfied (163 Votes)

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