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									                                          Substance Abuse Residential Facilities
                                          Data Collection Form
                                          January 2010

Instructions: Please complete all sections of this form and return by 5:00 p.m. on Friday,
February 19, 2010. The information is needed to document and report current utilization of
substance abuse residential services in the state and project future need for substance abuse
treatment services in the North Carolina State Medical Facilities Plan. We encourage you to
email the completed and signed form in a Portable Document Format (pdf) file to
DHSR.SMFP.Registration-Inventory@dhhs.nc.gov. If it is not possible to email the
completed form, you can mail it to Carol G. Potter, Medical Facilities Planning Section, 701
Barbour Drive, Raleigh, N.C. 27603. If you have questions, you can send an email to
DHSR.SMFP.Registration-Inventory@dhhs.nc.gov or call the Medical Facilities Planning
Section at (919) 855-3865. Thank you!

Section One: Contact Information

 Facility Name
                                      (use name listed on your current license)

 License Number:        MHL-



 Facility Location: Street address

                    City ___________________ State _________ Zip ______________


 Information Compiled or Prepared by:      (Name)

          Phone:    (      )

          Email:


 Signature of Licensee (or person with Signatory Authority):
  The undersigned, representing the governing authority, submits information for the above-
  named facility and certifies the accuracy of this information.


   Name _______________________            Phone (       )___________________________


   Signature ___________________________________                Date ___________________
                               2010 Substance Abuse Residential Facilities                            page 2 of 5
                               Data Collection Form

Section Two : Time Period for Report
      q 01/01/2009 – 12/31/2009   q Other time period: ____________________

Section Three: Licensure Categories
  The licensure category applicable to this form is in the table below. Please indicate if the facility is licensed to
  provide the service, and the number of licensed beds for the service.

10 NCAC 27G.License Categories: Licensure             Is the Facility Licensed to Provide       Number of Beds
Rules for Substance Abuse Facilities                        This Service? (yes / no)         Age 0-17     Age 18+
  Section .3400 Residential treatment/
  rehabilitation for individuals with substance
  abuse disorders                                          yes ______      no ______

Section Four: Reimbursement Source (comparable to required data from hospitals)
                                               Number of Discharges               Number of Patient Days of Care
                                               for the Report Period                 for the Report Period

                                         Age 0 - 17   Age 18+        Total      Age 0 - 17    Age 18+        Total

  (a) Total Medicare (Title XVIII)
  (b) Total Medicaid (Title XIX)

  (c) Other Payer Source

                                 Total

  Is your facility certified for Medicare/Medicaid?    __________ yes          _____________ no

Section Five: Days of Patient Care by County of Patient Origin
 Instructions: For each county, report the total days of care provided to patients from that county by area of
 treatment. For example, four patients from Alamance County, each receiving three days of Residential
 Treatment would result in a total of 12 days of care for Alamance County under Treatment. The total Days of
 Care should be the same as listed under Section Four, Reimbursement Source. Please do not include days of
 care information for halfway house services.
County Where the Facility is              Substance Abuse Residential
Located: __________________                 Treatment Days of Care            Residential Detox Days of Care

  County of Patient Origin               Age 0 - 17   Age 18+        Total      Age 0 - 17    Age 18+        Total
     Alamance
      Alexander
      Alleghany
      Anson
      Ashe
      Avery
      Beaufort
      Bertie

Name of facility (from page one) _______________________________________________
                            2010 Substance Abuse Residential Facilities               page 3 of 5
                            Data Collection Form

Section Five, continued: Days of Patient Care by County of Patient Origin
                                    Substance Abuse Residential
                                      Treatment Days of Care        Residential Detox Days of Care
 County of Patient Origin        Age 0 - 17   Age 18+     Total   Age 0 - 17   Age 18+      Total
    Bladen
     Brunswick
     Buncombe
     Burke
     Cabarrus
     Caldwell
     Camden
     Carteret
     Caswell
     Catawba
     Chatham
     Cherokee
     Chowan
     Clay
     Cleveland
     Columbus
     Craven
     Cumberland
     Currituck
     Dare
     Davidson
     Davie
     Duplin
     Durham
     Edgecombe
     Forsyth
     Franklin
     Gaston
     Gates
     Graham
     Granville
     Greene
     Guilford
     Halifax
     Harnett
     Haywood
     Henderson



Name of facility (from page one) _______________________________________________
                            2010 Substance Abuse Residential Facilities               page 4 of 5
                            Data Collection Form

Section Five, continued: Days of Patient Care by County of Patient Origin
                                    Substance Abuse Residential
                                      Treatment Days of Care        Residential Detox Days of Care
 County of Patient Origin        Age 0 - 17   Age 18+     Total   Age 0 - 17   Age 18+      Total
    Hertford
    Hoke
    Hyde
    Iredell
    Jackson
    Johnston
    Jones
    Lee
    Lenoir
    Lincoln
    Macon
    Madison
    Martin
    McDowell
    Mecklenburg
    Mitchell
    Montgomery
    Moore
    Nash
    New Hanover
    Northampton
    Onslow
    Orange
    Pamlico
    Pasquotank
    Pender
    Perquimans
    Person
    Pitt
    Polk
    Randolph
    Richmond
    Robeson
    Rockingham
    Rowan
    Rutherford
    Sampson
    Scotland
    Stanly
    Stokes
    Surry
    Swain
    Transylvania



Name of facility (from page one) _______________________________________________
                            2010 Substance Abuse Residential Facilities                   page 5 of 5
                            Data Collection Form

Section Five, continued: Days of Patient Care by County of Patient Origin
                                        Substance Abuse Residential
                                          Treatment Days of Care        Residential Detox Days of Care
 County of Patient Origin            Age 0 - 17   Age 18+     Total   Age 0 - 17   Age 18+      Total
    Tyrrell
    Union
    Vance
    Wake
    Warren
    Washington
    Watauga
    Wayne
    Wilkes
    Wilson
    Yadkin
    Yancey
    Other
                            Totals




Name of facility (from page one) _______________________________________________




Please return completed form by 5:00 p.m. Friday, 02/19/2010. We encourage you to email
the completed and signed form in a Portable Document Format (pdf) file to
DHSR.SMFP.Registration-Inventory@dhhs.nc.gov. If it is not possible to email the
completed form, you can mail it to Carol G. Potter, Medical Facilities Planning Section, 701
Barbour Drive, Raleigh, N.C. 27603. If you have questions, you can send an email to
DHSR.SMFP.Registration-Inventory@dhhs.nc.gov or call the Medical Facilities Planning
Section at (919) 855-3865.
                                        Thank you!


 DHSR - 4200 (rev. 01/2010)

								
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