NC DHHS HOME AND COMMUNITY BASED SETTINGS (HCBS) SELF-ASSESSMENT

Compliance with Statewide Transition Plan Alignment with CMS HCB Setting Regulation Requirements (42 CFR Sections 441.301 (c) (4) - (6); Section 441.302 and 441.530)

The following special characters are permitted within the assessment:     , . : ( ) - & / ; \
Any use of additional special characters will result in an assessment error preventing submission.

Section I: Settings That Are Not Home And Community Based

1. Is the facility one of the following?


2. Is the facility in one of the following locations?


Demographic Information


Section II: General HCBS Criteria

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No


I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for denial or termination of participation as a Medicaid Provider.

 
  
  

The following special characters are permitted within the assessment:    , . : ( ) - & / ; \
Any use of additional special characters will result in an assessment error preventing submission.
  

If you have feedback or questions, please email: [email protected].


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