How to Submit Forms and Applications
Fax the following forms and applications to the Division of Health Service Regulation at 919-733-9764:
- Name and Address Change Form
- Reciprocity Application
- RN and LPN Form
Use Credentia’s CNA365 system to submit the following application to the Division of Health Service Application:
- 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
Important Notices:
- Use the most current version of the forms and applications. Otherwise, your request will be denied.
- Do not email completed forms or applications to the Division of Health Service Regulation.
- Do not use a smart phone to complete the Online Renewal Form or the Online Employment Verification Form.
- Do not enter commas (,) in the text fields to separate information in the Online Renewal Form or the Online Employment Verification Form.
Denotes link to site outside of N.C. DHHS
