To apply to the Board for a provisional license, please download the application below.
The Board may issue a provisional administrator's license for a single period not to exceed six (6) months for the purpose of enabling a qualified individual to fill an administrator position that has been unexpectedly vacated. The facility owner or an officer of the facility's board of directors is required to complete a portion of the application and attach a detailed explanation on how the unexpected vacancy occurred within the facility that warrants the issuance of a provisional license. The provisional license that is issued can only be used at the particular facility that is specified on the application; it cannot be used at or transferred to any other facility.
The qualified individual must have at least two (2) years administrative experience in a licensed health facility. A complete resume documenting your administrative experience must be attached to the application. Include your employer, position, type of business, period of time worked, duties, type of facility (SNF, ICF, etc.) and number of beds in the facility.
Experience gained under provisional licensure shall not satisfy the education or administrator-in-training requirements for full health facility administration or residential care administration licensure.