North Carolina Department of Health and Human Services Forms

This form is used for individuals in North Carolina who are at risk of experiencing homelessness. It allows them to self-attest and verify their housing situation to receive necessary assistance and support.

This Form is used for third-party attestation regarding an individual's risk of homelessness in North Carolina.

This form is used for conducting a 24-hour facility exam in North Carolina for the purpose of involuntary commitment.

This Form is used for recertification in the Senior Community Service Employment Program in North Carolina.

This tipo de formulario se utiliza para solicitar el programa de asistencia de agua para familias de bajos ingresos en North Carolina.

This form is used for otolaryngological and otological applications in North Carolina.

This form is used for conducting health screening related to Covid-19 in North Carolina.

This document is a worksheet used in North Carolina to calculate income and assets for the NC ESG program.

This Form is used for the annual assessment of adult services in North Carolina.

This form is used for providing special assistance re-enrollment information notice in North Carolina.

This form is used for liability waiver for employees, activities leaders, class coordinators, and state employees' spouses and children who are 18 years old or older using the Haywood Gymnasium Facility in North Carolina.

This form is used for employees in North Carolina who are participating in fitness activities through work to waive liability.

This form is used for notifying the North Carolina Department of Social Services regarding any changes or updates to public assistance benefits, including modifications, terminations, or continuations.

This form is used for requesting the use of the Haywood Gymnasium facility in North Carolina.

This form is used for providing important information about the approval of Medicaid or Special Assistance in North Carolina.

This form is used for notifying a nursing home resident in North Carolina about a transfer or discharge.

This form is used for documenting work experience or community service agreements in North Carolina. It helps individuals track and share their work or service activities for various purposes such as resumes, job applications, or academic requirements.

This document is used for applying for Work First Cash Assistance in North Carolina. It also serves as a workbook for reviewing required documentation.

This form is used for referral purposes between the Division of Vocational Rehabilitation Services and County Social Services Agency/Department in North Carolina.

This Form is used for authorizing direct deposit of funds in North Carolina.

This Form is used for applying for the Low Income Energy Assistance Program in North Carolina.

This document is used for certifying the need for Medicaid coverage of inpatient psychiatric services in a Psychiatric Residential Treatment Facility (PRTF) for a beneficiary under the age of 21 in North Carolina.

This document is for creating an outreach plan for energy programs in North Carolina. It helps to organize and coordinate efforts to promote energy efficiency and renewable energy initiatives in the state.

This Form is used for emergency notification purposes in the state of North Carolina. It allows individuals to provide their contact information and other relevant details to receive important alerts and updates during emergencies.

This document is used for exiting the Nc Esg Client program in North Carolina.

This form is used for keeping track of case notes and activities within the Senior Community Service Employment Program in North Carolina.

This document describes the Transfer of Learning Tool (Tol) for in-home services in child welfare in North Carolina. It provides information and guidance on how to effectively transfer knowledge and skills for supporting families and ensuring child well-being.

This document describes the process for households in North Carolina to opt out of the Supplemental Nutrition Assistance Program (SNAP), also known as food stamps.

This form is used for researchers in North Carolina to apply for registration.

This type of document is used for certifying a master agreement in the state of North Carolina.

This document is a sample of a task order contract specifically designed for use in North Carolina. It outlines the terms and conditions for completing specific tasks or projects within the state.

This Form is used for submitting questions regarding the Refugee Assistance Policy in North Carolina.

This form is used for client registration in North Carolina.

This form is used for assigning community service tasks to individuals participating in the Senior Community Service Employment Program (SCSEP) in North Carolina.

This Form is used for reporting informal complaints related to Equal Employment Opportunity (EEO) in the state of North Carolina.

This form is used for hospitals in North Carolina to apply for registration with the Department of Health and Human Services.

This document describes the Crisis Prevention and Intervention Plan used in North Carolina to respond to emergencies and manage crisis situations. It outlines strategies, protocols, and resources to help prevent and address potential crises in various settings.

This form is used for self-attestation of an exclusion discovered after exiting a facility in North Carolina.

This Form is used for self-attestation as a veteran or spouse of a veteran in North Carolina.