gold_ball.gif (1008 bytes) Hospice Services Home Page
gold_ball.gif (1008 bytes) Applications
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gold_ball.gif (1008 bytes) Initial License
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Hospice Services
Applications

The following forms may be completed online but must be printed, signed and mailed to our office.  We require an original signature on all applications at this time.

PDF File Initial Licensure Application – Complete the initial application with current information, print application, obtain the appropriate signature(s), and submit with the additional required information and documentation detailed in the Initial Licensure Section. Mail the application to the Department with the required licensure fee.

Initial Licensure Application Addendum for Inpatient Hospice Facilities- Submit an PDF File Initial Licensure Application as directed with the additional required information and documentation detailed in the Addendum. Mail to the Department with the required licensure fee.

Initial Licensure Application Addendum for *New Construction of Inpatient Hospice Facilities- Submit an PDF File Initial Licensure Application as directed with the additional required information and documentation detailed in the Addendum. Mail to the Department with the required licensure fee.

*New Construction includes an addition to existing building, which will affect patient care or treatment areas of the hospice inpatient facility.

PDF File Renewal Licensure Application – Complete the renewal application with current information, print application, obtain the appropriate signature(s), and submit with the additional required information detailed in the Licensure Renewal Section. Mail the application to the Department with the required licensure fee.

If there are changes in information from the previous license application, complete the application with the current information including the date the change became effective.

Renewal Licensure Application Addendum for Inpatient Hospice Facilities- Submit a PDF File Renewal Licensure Application as directed with the additional required information and documentation detailed in the Addendum. Mail to department with the required licensure fee.

If there are changes in information from the previous license application, complete the application with the current information including the date the change became effective.

Change Notification Requirements: You must notify the Department in writing:

Within 5 working days, when a hospice is sold, leased, discontinued, or moved to a new location. PDF File 175 Nebraska Administrative Code (NAC) 16, Sections 004.04 and 004.06 (A new license is required when a change of ownership occurs, refer to Initial License Process.)

For additional Change Notification requirements see 175 NAC 16, Section 004.07.

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