10A NCAC 14E .0106      APPLICATION

(a)  Prior to the admission of patients, an applicant for a new clinic shall submit an application for licensure and receive approval from the Division.

(b)  Application forms may be obtained by contacting the Division at 2712 Mail Service Center Raleigh, NC 27699-2712.

(c)  The application form shall set forth:

(1)           Legal identity of the applicant;

(2)           The name or names under which the facility or services are advertised or presented to the public;

(3)           The facility's mailing address;

(4)           The facility's physical address;

(5)           The ownership of the facility, including a description of the legal character of the operating ownership;

(6)           The owner of the premises from which services are offered including the name and address of the owner of the premises if different from the owner of the facility;

(7)           If the facility is operated under a management contract, the name and address of the building's management company;

(8)           A description of the arrangements that have been made for the disposal of pathological waste, products of conception, and sharps, and the name and address of the provider of such services if not performed by the facility;

(9)           The name, specialty, board certifications, and medical license number of the Medical Director;

(10)         The name, specialty, board certifications, and medical license number of each member of the medical staff;

(11)         The name, nursing certificate number, and renewal number of the Director of Nursing;

(12)         The name, nursing certificate number, and renewal number of each nursing staff member; and

(13)         The name of the consulting pathologist, the name of the consulting pathologist's laboratory, and the address of the laboratory.

(d)  After construction requirements in Section .0200 of Subchapter 13S of Title 10A of the North Carolina Administrative Code have been met and the application for licensure has been received and approved, the Division shall conduct an on-site, licensure survey.

History Note:        Authority G.S. 131E-153; 131E-153.2; S.L. 2023-14, s. 2.4;

Eff. February 1, 1976;

Readopted Eff. December 19, 1977;

Amended Eff. July 1, 1994;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 24, 2019;

Codifier determined that agency's findings of need did not meet criteria for emergency rule on June 22, 2023;

Emergency Rule Eff. June 30, 2023;

Repealed Eff. July 1, 2023 pursuant to G.S. 150B-21.7;

Temporary Amendment Eff. December 22, 2023.