Forms

Name Change/Correction Form

Lost License and Replacement License

Online Portal Technical Support Request

Request to Add or Update a Facility

HSE and Combined ALD/NHA State exam application

State Exam Feedback Questionnaire

Continuing Education Approval Application

Continuing Education Provider Mailing Label Request Form

Request for Continuing Education Provider Mailing List

HSE Applicants Forms

HSE Shared Executive Application (PDF Fillable) 

Minnesota HSE Non-Renewal Form

ALD Applicant Forms

Permit Application 

Shared Residency Permit Application

Verification of Employment

State Exam application

Mentor Evaluation of ALDIR/ALD Mentee

Mentor Form Agreement

Permit Request Form (Complete when changing application type and you need to request a permit).

ALD Licensees Forms

Mentor Evaluation of ALDIR/ALD Mentee

Mentorship Interest Form

Shared Director Agreement

Education and Experience Review (PDF Fillable)

NHA Application for Initial Licensure (PDF Fillable)

Temporary Acting Administrator Permit for Skilled Nursing Facility (PDF Fillable)

NHA State Exam Application 

NHA Licensees Forms

NHA Licensee Shared Administrator Application 

HSE & NHA CE Attestation and Record Sheet (PDF fillable)

LNHA Employment Interest Registry

NHA New Licensee Survey