DHHS Licensure — Long-Term Care Facility License Renewal

A completed renewal form with authorized signatures and the required documentation listed below must be attached with your payment.

After attaching the renewal documents, click on “Make Payment” to proceed to PayPort and complete the renewal submission.

Credit/debit card OR checking account and routing information will be required.
A small transaction fee will be added to your payment. For some payments, selection of eCheck will give you a discount on your transaction fee.
We will email a receipt to the email address you provide. You may also print a receipt when the transaction is done.

Application Type Required

Facility License Number Required

Facility Name as shown on renewal application Required

Facility Street Address Required

Facility City Required

Facility Contact Email Address Required

Additional Email Address

Required attachments for all renewals - Total file size for all files cannot exceed 17 MB. Pdf, doc, docx, jpg, png, gif, and tiff formats are preferred.

Completed renewal form with authorized signatures Required

Ownership/control list with the names and addresses of all owners or persons in control of the facility Required

Occupancy certificate issued by the State Fire Marshal or their delegated authority, dated within the last 18 months Required

Floor plan and bed count Required

Required attachments, if applicable to the facility

If deemed status is requested, attach the current accreditation report

If Alzheimer’s or dementia care is provided, attach a completed Alzheimer’s Special Care Disclosure and Memory Care Endorsement Application Download the necessary form here.

If sole proprietor, attach the lawful presence attestation form Download the necessary form here.

If individual ownership, attach a document with the owner’s Social Security number

Security Authentication Required

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