Get Nc Dhsr/ac 4207 2011-2025

The NC DHSR/AC 4207 is a vital document used to register residents in various facilities. This guide offers a clear, step-by-step approach to help users complete the form accurately and efficiently, ensuring compliance with state regulations.

Follow the steps to fill out the NC DHSR/AC 4207 online correctly.

1. Click ‘Get Form’ button to obtain the NC DHSR/AC 4207 and open it in the online editor.
2. Begin with section A. Fill in the identifying information, including the name of the home or facility where the resident is being admitted.
3. Complete the resident's name by providing the first, middle, and last names, as well as the name they prefer to be called.
4. Enter the date of admission in the specified format: month, day, and year.
5. List the former address of the resident and the county, noting the source of admission, whether from their own residence, another's residence, or another facility.
6. Provide the resident's birth date, birthplace, and Social Security number carefully.
7. Input insurance details, including Medicare, Medicaid, and any other insurance numbers.
8. Select the marital status from the provided options and indicate the gender of the resident.
9. Identify the race using the corresponding categories included in the form.
10. Complete the family information section, including names of the father, mother (including maiden name), children, siblings, and spouse or partner if applicable.
11. If applicable, fill in the details of the responsible person, including their relationship to the resident and contact information.
12. Identify a contact person if the responsible person is not designated.
13. Provide the name of the person identified by the resident to receive a copy of the discharge notice.
14. Move to section B and input the attending physician's and previous physician’s details along with plans made for payment of personal needs.
15. In section C, indicate the assistance required for daily activities by checking all applicable boxes, and provide additional details if necessary.
16. List any memory issues and special aids that the resident may require.
17. Record personal habits, known allergies, and food preferences in the appropriate sections.
18. Complete all sections related to community involvement, including activities, hobbies, and interests.
19. In section D, request assistance as needed, ensuring that all necessary signatures are collected.
20. Acknowledge receipt of materials listed in section E once reviewed with the resident.
21. In section F, ensure that the signatures for both the resident and the administrator or supervisor-in-charge are obtained after all previous sections have been completed.
22. Finally, complete section G for discharge/transfer information, ensuring accuracy in dates and reasons.
23. Once all fields are filled out, save changes, download a copy, or print the form for necessary records.

Complete your NC DHSR/AC 4207 online today to ensure a smooth admission process.