Issuing Of Duplicate License-Duplicate Administrator License Request Form printable pdf download

Issuing Of Duplicate License-Duplicate Administrator License Request Form

BOARD OF EXAMINERS OF NURSING CARE INSTITUTION ADMINISTRATORS AND

ASSISTED LIVING FACILITY MANAGERS

1400 West Washington, Suite B – 8 Phoenix, Arizona 85007

(602) 364-2374 phone

(602) 542-8316 fax

Douglas A. Ducey

Allen Imig

Email:

information@aznciaboard.us

Website

Governor

Executive Director

Issuing of Duplicate License

On June 6, 2015, an administrator is allowed to oversee a second nursing care institution if

neither facility is under a provisional license, the two facilities are no more than 25 miles apart

and the appointment at the second facility is no longer than 90 days. There are also other

conditions that have to be met when overseeing a second facility. Refer to AAC R4-33-212.

This change directly affects duplicate licenses and how the issuance and tracking will be

accomplished. NCIA Board rules allow the Board to be specific in where the duplicate will be

placed and the extent of its use.

Below is how the Board will issue and track duplicate licenses.

 The duplicate license will be for a specific location and list the name and address of the

facility.

 The duplicate license will be valid only as long as the administrator remains appointed at

the location listed on the duplicate license but for no longer than 90 days, and their

administrator’s license remains current.

 The duplicate license cannot be used at any other location.

 If the administrator appointment ends at the location listed on the duplicate, the duplicate

license is no longer valid.

 When the administrator appointment ends at the location on the license, the duplicate

license must immediately be returned to the Board.

 If the administrator is appointed at a new location, a new duplicate license needs to be

obtained from the NCIA Board for that new location.

 If the administrator’s license is suspended, revoked, limited or expired, the duplicate has

that same status.

 If the facility information and location is not filled out on the request form, a duplicate

will not be issued.

This will allow the Board to receive the notice and or termination of appointment per AAC R4-

33-211 and meet the display of license requirement per AAC R4-33-108.

Issuing Of Duplicate License-Duplicate Administrator License Request Form