Hurricane Helene Telepractice Waiver Form

Information for individuals completing this form

For those licensees impacted in North Carolina by Hurricane Helene or serving the North Carolina public impacted by Hurricane Helene, please state your question(s) or requests regarding a waiver of the statutory requirements of the practice of Speech-language Pathology or Audiology in or from the state of North Carolina, the Board will respond as soon as possible and may request additional information. If electronic delivery of this form is not possible, you may call the Board at 336-272-1828 x2 and receive assistance filling out the form verbally.

Licensee/Registrant Name(Required)

Prefix First Middle Last

License number (if applicable)(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

State where I will be located at the time I provide telepractice(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position(Required)

Licensee/ Temporary Licensee/ Registrant

Out of State Practitioner

Student/ Applicant

Signature(Required)

I hereby certify and affirm that I have reviewed the laws and rules of the state where I will be located at the time I provide telepractice and am legally permitted to engage in telepractice in NC under waiver/allowance #3 and #4 which can be found here: https://ncboeslpa.org/helene-waiver-request-forms-and-waivers/

Email for PDF delivery of submission

Enter your email address here if you wish to receive a copy of your responses.

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OTC Hearing Aids and "Prescription" Hearing Aids Resource Page view page

Information for individuals completing this form