DSS-6189 State Maternity Fund Residential Care Provider Agreement - info dhhs state nc-2026

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  1. Click ‘Get Form’ to open the DSS-6189 agreement in the editor.
  2. Begin by filling in the names of the Service Agency and Care Provider in the designated fields at the top of the form.
  3. Enter the location of the Care Provider and specify the reimbursement amount per day for room and board services.
  4. Indicate the date when the Client will move into the Care Provider’s facility, ensuring accuracy for reimbursement tracking.
  5. Complete sections detailing accommodations, meals, and utilities that will be provided to the Client during their stay.
  6. Fill out emergency contact information as required, including names and phone numbers for immediate notification.
  7. Review all entered information for accuracy before signing. Ensure both parties sign and date at the bottom of the form.

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