Dhsr 4204-2026

The document is a licensure application form from the North Carolina Department of Health and Human Services for home care, nursing pool, and hospice services. It outlines the requirements for applicants, including legal identity, agency information, services offered, accreditation details, ownership disclosure, and certification of accuracy. The form must be completed for each site providing these services and includes sections for various service categories and ownership structures.

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Click ‘Get Form’ to open the dhsr 4204 in the editor.
Begin by filling out the 'Legal Identity of Applicant' section. Enter the full legal name of your corporation or partnership, ensuring accuracy for compliance.
In the 'Agency Name/Doing Business As' field, provide the name under which your services are advertised. Include your mailing address and site address accurately.
Check all applicable licensure categories you are applying for, such as Home Care Agency or Hospice Services. This is crucial for proper classification.
Complete the 'Scope of Services' section by checking each service offered through your site. Ensure that you indicate whether services are provided in-house or through contracts.
Fill out ownership disclosure details accurately, specifying whether your entity is for-profit or not-for-profit and providing necessary information about partners or corporate structure.
Finally, certify the application by signing and dating it at the bottom of the form to confirm that all information is true and accurate.

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