New York State Nursing Home Administrator Licensure Application Instructions

General Guidelines

When completing the Nursing Home Administrator Licensure Application (DOH-641), please adhere to the following:

  1. Type or print responses legibly in black or blue ink.
  2. Complete all sections of the application. Before submitting, be sure that all sections of the application are completed fully and the application is signed, dated, and notarized. Incomplete and/or incorrect applications will be returned.
  3. If more space is needed to provide information for any of the questions, please use additional sheets of paper. Indicate the section of the application and the question/issue to which the information pertains. Attach sheets in the order the sections appear in the application.
  4. Send copies of two government issued forms of identification (ID) with your application. At least one of the forms of ID must state your date of birth and at least one must be a photo ID. Acceptable forms of ID are listed at the end of these instructions.
  5. Have an official copy of your college transcript(s) sent directly from the college(s) or send the transcript in an envelope sealed by the college and unopened. Do not send student copies of your transcript unless requested to do so by staff. The transcript must indicate the date the degree was conferred. Include transcripts for all undergraduate and graduate level courses completed. Do not send a copy of your diploma or degree.
  6. Attach course descriptions establishing your fulfillment of the required coursework as detailed in Licensure Qualification 3. The course number(s) identified on the course description(s) must correspond to the course number(s) listed on your transcripts. Do not forward the entire course catalog. Send only copies of relevant course descriptions from the catalog applicable to the course(s) you completed.
  7. Application Fee: Payment of the licensure application fee must accompany your application. Payment must be made by check or money order payable to "New York State Department of Health," in the amount of forty dollars ($40.00) U.S. funds.
  8. Examination Fee: Do not submit payment for the examination at this time. You will be requested to submit the required examination fee directly to the examination service only after the Board has approved your licensure application.
  9. Applicants interested in participating in the Board of Examiners of Nursing Home Administrators' AIT Program to acquire the necessary experience to fulfill Licensure Qualification 4, must submit a completed licensure application prior to participating in the program. Additionally, the Board must approve the AIT program, the preceptor, and the training site before the start of any AIT training program.
  10. New York State does not issue nursing home administrator licenses by reciprocity. In order to obtain a New York State Nursing Home Administrator's license, you must submit a completed application in accordance with the general instructions detailed above, establishing that you fulfill all of the requirements for licensure in New York State.

Section A (Identifying Data)– You must answer all questions in this section. Make sure to include:

  • full middle name;
  • all maiden and other names previously used;
  • complete address including apartment # (if applicable) and extended zip code;
  • complete e-mail address; and
  • home and business telephone numbers.

Section B (Employment Data) – Enter your employment history for the past ten years only. Use extra sheets as necessary.

Section C (Formal Education) – Complete all applicable sections.

Section D (Internship) – Answer both questions.

Section E (Professional Licensure) – Make sure to check "yes" or "no" as applicable. Enter the names of all states that have issued you a license and list the license number(s). If you also possess a current five-year certification from the American College of Health Care Administrators, indicate this, as well. List all other professional licenses (i.e.: nursing, physical therapy) in this section.

Section F (Character and Suitability) – You must answer all questions. If you answer "yes" to any of these questions, you must submit a letter of explanation and include any applicable court records.

Section G (Service in the Armed Forces) – You must answer both questions and, if applicable, include a copy of your discharge papers.

Section H (Child Support Obligation) – You must answer this question.

Section I (Notarized Signature) – You must sign and date the completed application witnessed by a notary public.

Questions

Questions regarding the completion and submission of the licensure application or the qualifications for licensure as a nursing home administrator should be directed to the Board of Examiners of Nursing Home Administrators at 518-408-1297. Staff will be happy to assist you.

Please bear in mind, staff will be unable to advise you as to whether you are in fulfillment of specific licensure qualifications until your application has been submitted and reviewed. Your patience and cooperation during the review period are appreciated.

Submission

When completed, mail your completed, signed and notarized Nursing Home Administrator Licensure Application form (DOH-641), supporting documentation, and forty dollar ($40.00) application fee payment to:

Board of Examiners of Nursing Home Administrators
NYS Department of Health
Bureau of Professional Credentialing
161 Delaware Avenue
Delmar NY 12054-1393

Acceptable Forms of Identification

(Two forms of the following ID are required. Your birth date must be on at least one and one must be a photo ID.)

  1. U.S. Passport (unexpired or expired)
  2. Certificate of U.S. Citizenship (Form N-560 or N-561)
  3. Certificate of Naturalization (Form N-550 or N-570)
  4. Unexpired foreign passport with I-551 stamp or attached Form I-94 indicating unexpired employment authorization
  5. Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-151 or I-551)
  6. Unexpired Termporary Resident Card (Form I-688)
  7. Unexpired Employment Authorization Card (Form I-688A)
  8. Unexpired Reentry Permit (Form I-327)
  9. Unexpired Refugee Travel Document (Form I-571)
  10. Unexpired Employment Authorization Document issued by DHS that contains a photograph (Form I-688B)
  11. Driver's License or ID card issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address
  12. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address
  13. School ID with a photograph
  14. Voter's registration card
  15. U.S. Military card or draft record
  16. Military dependent's ID card
  17. U.S. Coast Guard Merchant Mariner Card
  18. Native American tribal document
  19. Driver's license issued by a Canadian government authority