DHSR/HCPEC-4515 is a form used for the reciprocity application process for nurse aides seeking to be listed on the North Carolina Nurse Aide I Registry without additional examination. This form is specifically designed for nurse aides already certified in another state and wish to transfer their certification to North Carolina. The application requires information about the applicant’s current certification, personal identification details, and employment history in the healthcare field to verify their qualifications and experience.
Form DHSR/HCPEC-4515 is designed to streamline the verification process for nurse aides moving to North Carolina, ensuring they can continue practicing without interruption. By facilitating this interchange, the state ensures that qualified healthcare professionals can seamlessly integrate into the healthcare system, helping to meet the workforce needs of various healthcare settings.
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Follow our guide to understand how the template should be completed.
Read the General Instructions
The template starts with a set of general instructions every filer should read. It is vital to read these instructions because they send you to the first part of the form, where you will define if you can or cannot create the document. Read everything carefully and check the first part to ensure that you are an eligible applicant.
There are five requirements for everyone who applies. For example, you should not have any findings of neglect or abuse of residents or patients. Also, you have to complete all listed educational programs.
Provide Personal Info
In the second part, you will provide personal details. Begin with your full name (first, middle, and last) and previous names (if you have any). Choose your gender; then, enter your SSN (social security number), email address, phone number with an area code, birth date, and mother’s maiden last name.
Answer if you have ever served in the military and if you have performed any medical tasks there. Then, reply if you are now married to a military service member.
Enter your full mailing address and proceed to Part 3.
Answer about the Educational Program
You have to provide responses about the state-approved Nurse Aide I Training & Competency Evaluation Program. Answer if you have finished the program and passed the exam after it.
Complete Part 4
Here, you should indicate all American states where you have nurse aide I registration. For each state, enter its name or acronym of two letters, state if your registration is still active, add issue and expiration dates along with the certificate number.
The chart presumes you enter three states. If there are more, mark the “yes” box under the chart and attach a sheet with details. Answer the last question in Part 4 and move to the next part.
Define Your Employment Type
Mark the boxes describing your workplace(s) during the last two years (hospital, home care, hospice, nursing home, and so on). If nothing is relevant, you can insert your place in the designated line. You can also mark the box telling that you were not working as a nurse during the last two years, but you completed the required educational program.
Tell about Your Employment
You should provide your employment history in Part 6. The template allows you to write about two employers; if you have more within the past two years, attach a separate sheet with a description. For each employer, enter the name, address, dates when you were working. Answer additional questions about the employer below the chart.
Check the List of Documents to Provide
Along with this form, you will have to submit some more documents. The list is added to Part 7 together with the requirements. Read this part carefully and ensure you have provided everything demanded.
Sign the Document
Finally, you must sign the document to prove that everything you have written is true and correct. Keep in mind that all details you have inserted in the document will be thoroughly checked by the Division workers. If you lie, it will eventually be discovered, and you will face trouble.
Enter your first, middle, and last name line by line. Then, sign and date the record.
While the completion process is quite easy, you still might have questions about the form. The NC DHSR is ready to answer them: see contact phone numbers on its site.
After you have finished working on the form, you have to submit all its pages and related documents to the NC DHSR. Check its website as well to see the current options on how to file papers. The Division will review your application and contact you then. It can decline your application if the one who checks your form and all details have doubts. However, you will be able to fix it and re-apply.
