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.
 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 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 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.
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 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. 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. |
