Addendum To Initial License Application For Inpatient Hospice Facilities

Initial Licensure Requirements for Inpatient Hospice Facilities

• Completed Initial Licensure Application: The applicant must submit a completed Initial License Application and the following information required and documentation as required in 175 NAC 16, Section 003.01B;
• List of names and addresses of all persons in control of the service. 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;
• Copy of the registration as a foreign corporation filed with the Nebraska Secretary of State, if applicant is a foreign corporation; Required licensure fee specified in 175 NAC 16, Section 004.10.
• Number of Beds;
• Planned occupancy date;
• Copies of zoning approval from the relevant jurisdiction; and
• Occupancy certificates issued 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.