Application for License to Operate a Nursing Facility
Name and Location of Facility
Name and Location of Facility
Legal Business Name:
Must be exactly as name appears on legal documents.
Do you have a DBA (Doing Business As)?
Yes
No
DBA Name:
Must be exactly as name appears on legal documents.
Contact Information
Contact Information
Telephone Number:
Extension:
Fax Number:
Extension:
Administrator
Administrator
First Name:
Last Name:
Title:
Email Address:
Physical Address
Physical Address
Address of Facility:
Address Line 2:
City:
County:
Please select
Aurora
Beadle
Bennett
Bon Homme
Brookings
Brown
Brule
Buffalo
Butte
Campbell
Charles Mix
Clark
Clay
Codington
Corson
Custer
Davison
Day
Deuel
Dewey
Douglas
Edmunds
Fall River
Faulk
Grant
Gregory
Haakon
Hamlin
Hand
Hanson
Harding
Hughes
Hutchinson
Hyde
Jackson
Jerauld
Jones
Kingsbury
Lake
Lawrence
Lincoln
Lyman
Marshall
McCook
McPherson
Meade
Mellette
Miner
Minnehaha
Moody
Oglala Lakota
Other
Pennington
Perkins
Potter
Roberts
Sanborn
Spink
Stanley
Sully
Todd
Tripp
Turner
Union
Walworth
Yankton
Ziebach
State:
Please select
ND
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GM
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
OT
ZIP Code:
Mailing Address
Mailing Address
Is your mailing address different from the address above?
Yes
No
Mailing Address:
Address Line 2:
City:
State:
Please select
ND
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GM
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
OT
ZIP Code:
Capacity and Classification of Facility
Capacity and Classification of Facility
Number of Licensed Beds:
Are you accredited?
Yes
No
Accredited by:
Please select
Commission on Accreditation of Rehabilitation Facilities
Joint Commission
Date:
Upload current accreditation reports and correspondence.
Upload File(s)
Click
here
for recommendations on uploading files.
If the requested documents were submitted previously, give date:
Submit & Continue
EXIT
