Registration and Inventory Forms

These are the forms on which to report information related to the legally required "Registration and Inventory of Medical Equipment" (G.S. § 131E-177). On these forms, owners and providers certify that they owned, leased, or operated equipment cited in G.S. § 131E-176 and utilized this equipment to perform services at specific sites in North Carolina.

Please download the appropriate form(s) for your facility, complete all sections and return to Healthcare Planning by Friday, January 26, 2018.

  1. Complete and sign the form
  2. Return the form by one of two methods:
    1. Email a scanned copy to DHSR.SMFP.Registration-Inventory@dhhs.nc.gov
    2. Mail the form to Sharetta Blackwell, Healthcare Planning, 2704 Mail Service Center, Raleigh, N.C. 27699-2704

Note: Fixed equipment operated in a facility licensed under a hospital should be reported on that hospital's license renewal application, and not duplicated on this form.

If you have questions, call Amy Craddock in Healthcare Planning at 919-855-3865 or email DHSR.SMFP.Registration-Inventory@dhhs.nc.gov.

Forms