The state of North Carolina requires licensed healthcare facilities to complete and submit a licensure renewal application form each year. You can download a working copy of the hospital form here. A copy of the Ambulatory Surgery Center Form and instructions is also available for those with separately licensed ambulatory surgery facilities.
Note the electronic documents are intended for internal use. The Division of Health Service Regulation (DHSR) requires that the printed/mailed version you received be completed and returned to them.