ATTACHMENT Z
8/2012
STATE OF NEBRASKA
APPLICATION FOR A NURSING HOME
Department of Health and Human Services
ADMINISTRATOR OVERSEEING UP TO
Division of Public Health – Licensure Unit
3 LICENSED FACILITIES
PO Box 94986; Lincoln, NE 68509-4986
Telephone #: (402) 471-4918 rita.watson@nebraska.gov
NO FEE REQUIRED
SECTION A – PERSONAL INFORMATION
(verification of licensure can be found on the INTERNET under
1
Name:
First:
Middle:
Last:
2
Address:
Street/PO/Route:
City:
State:
Zip Code:
3
Date of
Place of Birth:
Birth:
4
Phone number optional:
Check the
5
Social Security Number (SSN);
SSN#
Appropriate Box(s):
Alien Registration Number (“A#”); or
Form I-94 (Arrival-Departure Record) number:
A#
I-94 #
If you have both a SSN and an A# or I-94 number, you must report both.
Neb. Rev. Stat. §38-123 mandates disclosure of your social
security number to DHHS. Although your number is not public information, DHHSs may disclose it for child support enforcement purposes and to
the Nebraska Department of Revenue.
SECTION B – FACILITIES (Complete the following information relating to the facilities that you plan to oversee)
Name of Nursing Home:
Address:
Street/PO/Route:
1
City:
State:
Zip:
Number of Beds:
Name of Nursing Home:
Address:
Street/PO/Route:
2
City:
State:
Zip:
Number of Beds:
Name of Nursing Home:
Address:
Street/PO/Route:
3
City:
State:
Zip:
Number of Beds:
Each administrator must be responsible for and oversee the operation of only one licensed facility or one integrated system, except that
an administrator may make application to the board for approval to be responsible for and oversee the operations of a maximum of 3
licensed facilities if such facilities are located within 2 hours’ travel time of each other or to act in the dual role of administrator and
department head but not in the dual role of administrator and director of nursing. An administrator responsible for and overseeing the
operations of any integrated system is subject to disciplinary action against his/her license for any regulatory violations within each
system.
1
2
3
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