Fillable N.C. Department of Health and Human Services (North Carolina)

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N.C. Department of Health and Human Services (North Carolina)

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N.C. Department of Health and Human Services
Division of Health Service Regulation
Offic
e of Emergency Medical Services
2707 Mail Service Center ■ Raleigh, North Carolina 27699-2707
Notice of Voluntary Health Care Services
Name of Sponsoring Organization:
Voluntary Health Service On-Site Location:
Date of Service:
List of Health Care Providers:
1. Name:
2. Date of Birth:
3. State of Licensure:
4. License Number:
5. Area of Practice:
6. Practice Address:
On-Site Health Care Provider with Access to Control Substances Reporting System
(G.S. 90-113.73):
1. Name:
2. Area of Practice:
3. NC License Number:
DHHS/DHSR/OEMS 4916 Effective Date 01/01/2013
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N.C. Department of Health and Human Services (North Carolina)

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Completed 21 February 2022

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