How to Submit Forms and
Applications
Email the following forms and applications to the Division of Health Service Regulation at [email protected]. You must submit the most current
version of each form and application.
- Registry Verification and Change Request Form
- Reciprocity Application
- RN and LPN Form
The Division of Health Service Regulation has partnered with Credentia Nurse Aide LLC for Candidates to submit the following application. Click here to go to Credentia’s website. You will be required to log into their system to complete and submit the application for review and approval.
- Training Waiver Application
Complete the following forms online at the Division of Health Service Regulation website:
- Nurse Aide Online Renewal Form
- Nurse Aide Online Employment Verification Form
- Medication Aide Online Renewal Form
- Medication Aide Online Employment Verification Form
Nurse Aide and Medication Aide Guidelines:
- Submit separate Online Renewal Forms for listings in the Nurse Aide I Registry and the Medication Aide
Registry for Nursing Homes.
- Submit the Online Renewal Form within 90 days prior to the registry listing expiration date.
- Please be advised that the last date worked as a Nurse Aide or Medication Aide must be within the
registration/listing period identified in the form.
- The online renewal forms do not renew a Nurse Aide II listing with the North Carolina Board of Nursing.
Technology Guidelines:
- When emailing documents to DHSR, please send in PDF or Word format.
- Do not use the Internet Explorer web browser when completing the forms.
- Do not use a smart phone when completing the forms.
- Do not enter commas (,) in the text fields to separate information in the Online Renewal Form or the
Online Employment Verification Form.
- Contact your Information Technology department within your organization to ensure firewalls will allow
the online renewal forms to be submitted to DHSR.
First Name and Last Name Requirements:
- The First Name and Last Name entered in the online renewal forms must match the First Name and Last Name
listed in the registries – including hyphens and suffixes.
- The Nurse Aide or Medication Aide should complete the Registry Verification and Change Request Form if
their legal name is not reflected in the registries. Click here to obtain the form.
- Do not include apostrophe’s when entering the First Name or Last Name. If the First Name or Last
Name includes an apostrophe in the registry, and that is the correct spelling of the name, then there is
no need to complete the Registry Verification and Change Request Form.
Registered Nurse Guidelines:
- The Registered Nurse must have an active and unencumbered license to practice in North Carolina.
- The Registered Nurse must be the direct supervisor of the Nurse Aide or Medication Aide or has direct
access to employer files. Employment that the Registered Nurse cannot support within the employer files
or by personal supervision (and thereby knowledge of the employment date) does not meet the requirements
for renewal.
- The Registered Nurse is not attesting to the competency of the Nurse Aide or Medication Aide.
- The Registered Nurse should submit separate Online Employment Verification Forms for listings in the
Nurse Aide I Registry and the Medication Aide Registry for Nursing Homes.
- The Registered Nurse must submit the Online Employment Verification Form within 7 calendar days after
the Nurse Aide or Medication Adie submits the Online Renewal Form. After 7 calendar days, both renewal forms
must be submitted again.
- The Registered Nurse is not required to enter dashes (-) when entering their license number.
-
The Registered Nurse can find the facility license number by completing one of the following activities
below:
- Review the DHSR licensure certificate posted within the healthcare facility.
- Click here to review DHSR facility
information for your provider type (e.g., nursing home, hospital, etc.).
- Click here to find the contact
information for the DHSR Licensure Section for your provider type (e.g., nursing home, hospital,
etc.).
Denotes link to site outside of N.C. DHHS
