Addendum To Licensure Renewal Application for Inpatient Hospice Facilities
Licensure Renewal Requirements for Inpatient Hospice Facilities
Completed Licensure Renewal Application. The applicant must submit a completed Licensure Renewal Application and the following information required and documentation as required in 175 NAC 16, Section 003.02A. For a renewal application, please call 402-471-4967.
- Required licensure fee specified in Title 175 Chapter 16, Section 004.10.
- List of names and addresses of all persons in control of the hospice. The list must include all individual owners, partners, limited liability company members, parent companies, and members of boards of directors owning or managing the operations and any other persons with financial interests or investments in the service. In the case of publicly held corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s stock.
- Number of beds (Changes in the use and location of beds may occur at any time without prior Department approval for licensure purposes).
- Occupancy Certificate issued, within 12 months prior to the expiration date, by the State Fire Marshal or delegated authority.
Documents in PDF format require the use of Adobe Acrobat Reader which can be downloaded for free from Adobe Systems, Inc.