Form Mo 580 2988 – Fill Out and Use This PDF

To renew yourAdministratorʼs license: Completeallfieldsinthisform, include a check or money order made payable to “Department of Health and Senior Services” and mail to the DHSS/BNHA Fee Receipts Office by May 30th of the current renewal year.

The $25 late fee will not apply unless your renewal application is postmarked AFTER June 30th of the current renewal year.

STEP 1 OF 4 - OFFICIAL BOARD INFORMATION (PLEASE MAKE ANY NECESSARY CHANGES AND/OR SUPPLY INFORMATION NOT LISTED)

ADDRESS

DATE EMPLOYMENT BEGAN IN CURRENT POSITION, IF ADMINISTRATOR

STEP 2 OF 4 - BACKGROUND QUESTIONS

1.HAVE YOU EVER BEEN CHARGED WITH, ARRESTED FOR, OR CONVICTED OF AN OFFENSE INVOLVING THE OPERATION OF A LONG-TERM CARE OR OTHER HEALTH CARE FACILITY?

YES NO

2.HAVE YOU EVER BEEN CHARGED WITH, ARRESTED FOR, OR CONVICTED OF A CRIME, AN ESSENTIAL ELEMENT OF WHICH DISHONESTY, FRAUD OR MORAL TURPITUDE?

YES NO

3.HAVE ANY OF YOUR OTHER PROFESSIONAL LICENSES EVER BEEN DISCIPLINED?

YES NO

*If you marked yes to any of these questions, please attach an explanation with any arrest, conviction and court documentation. If any of your professional license(s) have been disciplined, and this information was not provided to the Board at any time prior to this renewal, please explain and attach a copy of any settlement agreement, contract, etc. that you entered into at the time of discipline.

STEP 3 OF 4 - SIGNATURE

I hereby affirm under the penalty of perjury, that all information contained in this application is true and correct to the best of my knowledge and belief and that all supporting documents will be maintained in my file for four years. I understand that falsification of information may constitute grounds for discipline of my license pursuant to Section 344.050, RSMo.

STEP 4 OF 4 - CERTIFICATION OF CONTINUING EDUCATION FOR RENEWAL - PAGE 2

MO 580-2988 (3-11)

STEP 4 OF4 - CERTIFICATION OF CONTINUING EDUCATION FOR RENEWAL (DO NO ATTACH EVIDENCE OF CLOCK HOURS COMPLETED FOR RENEWAL)

SEMINARS - Must include a minimum of 40 clock hours including 10 hours of patient care (PC). If additional space is needed, feel free to copy this page.

ON-LINE PROGRAM(S) - Please list, up to a maximum of 20 clock hours, any MO BNHA-approved on-line program(s) you completed for license renewal.

OTHER METHODS OF EARNING CLOCK HOURS - A maximum of 5 clock hours toward the 20 may be awarded for the following: publishing health-care related articles of at least 1500 words; serving as Missouri preceptor for a nursing home administrator-in-training (1 clock hour for each full month serving as a preceptor), and; lecturing at a board-approved seminar (1 clock hour for each hour of presentation time up to a maximum of 3 hours, which can be in addition to actual hours of attendance at the seminar).

*TOTAL HOURS

*A minimum of 40 clock hours including 10 pc hours. Any hours in excess of the 40 required will not carry over.

MO 580-2988 (3-11)