Form NH-6 "Request for Reciprocity Verification of Out-of-State Licensure Status" - New Jersey

What Is Form NH-6?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2021;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NH-6 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form NH-6 "Request for Reciprocity Verification of Out-of-State Licensure Status" - New Jersey

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New Jersey Department of Health
Nursing Home Administrators Licensing Board
Mailing Address:
Overnight Services (UPS, FedEx, Airborne):
PO Box 358
120 South Stockton Street, 3rd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
REQUEST FOR RECIPROCITY
VERIFICATION OF OUT-OF-STATE LICENSURE STATUS
SECTION I - TO BE COMPLETED BY APPLICANT
Please complete the requested information in Section I.
Forward a separate form to the State Nursing Home Administrators Licensing Board
in each state in which you are/were licensed as a Nursing Home Administrator.
Name
First
M.
Last
Social Security Number
Current Home Address
Date of Birth
City, State, Zip
Day Telephone Number
Evening Telephone Number
PERMISSION FOR RELEASE OF INFORMATION
I hereby give my permission to the Nursing Home Administrators Licensing Board in
the State of
to release necessary information to the
New Jersey Nursing Home Administrators Licensing Board for the purpose of licensure verification.
Date
Signature
SECTION II
TO BE COMPLETED BY THE STATE NURSING HOME ADMINISTRATOR LICENSING BOARD WHERE LICENSE WAS GRANTED
The individual named above has applied for licensure as a Nursing Home Administrator in New Jersey.
Please provide the following information regarding this applicant and return this form to the above address.
NHA License Number
Date License Initially Issued By Your State
License Expiration Date
Did this individual participate in a nursing home administrator licensure examination?
Yes
No
Number of AIT hours completed:
If Yes, type of examination:
NAB
PES
NAB/PES (1982-Present)
Date of Examination:
Form No.:
Total Raw Score:
Total Scaled Score:
If No, was equivalency/reciprocity granted from another state?
No
Yes - Name of state:
Is this individual in good standing with your Board?
Yes
No - Explain:
Has any disciplinary or licensure action (i.e., reprimand, formal hearing, censure, suspension, revocation, etc.) been taken against this
individual by your Board or any other state agency?
No
Yes (Please attach explanation)
Name of Board Chair/Representative
Title
Date
Signature
NH-6
AUGUST 21
New Jersey Department of Health
Nursing Home Administrators Licensing Board
Mailing Address:
Overnight Services (UPS, FedEx, Airborne):
PO Box 358
120 South Stockton Street, 3rd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
REQUEST FOR RECIPROCITY
VERIFICATION OF OUT-OF-STATE LICENSURE STATUS
SECTION I - TO BE COMPLETED BY APPLICANT
Please complete the requested information in Section I.
Forward a separate form to the State Nursing Home Administrators Licensing Board
in each state in which you are/were licensed as a Nursing Home Administrator.
Name
First
M.
Last
Social Security Number
Current Home Address
Date of Birth
City, State, Zip
Day Telephone Number
Evening Telephone Number
PERMISSION FOR RELEASE OF INFORMATION
I hereby give my permission to the Nursing Home Administrators Licensing Board in
the State of
to release necessary information to the
New Jersey Nursing Home Administrators Licensing Board for the purpose of licensure verification.
Date
Signature
SECTION II
TO BE COMPLETED BY THE STATE NURSING HOME ADMINISTRATOR LICENSING BOARD WHERE LICENSE WAS GRANTED
The individual named above has applied for licensure as a Nursing Home Administrator in New Jersey.
Please provide the following information regarding this applicant and return this form to the above address.
NHA License Number
Date License Initially Issued By Your State
License Expiration Date
Did this individual participate in a nursing home administrator licensure examination?
Yes
No
Number of AIT hours completed:
If Yes, type of examination:
NAB
PES
NAB/PES (1982-Present)
Date of Examination:
Form No.:
Total Raw Score:
Total Scaled Score:
If No, was equivalency/reciprocity granted from another state?
No
Yes - Name of state:
Is this individual in good standing with your Board?
Yes
No - Explain:
Has any disciplinary or licensure action (i.e., reprimand, formal hearing, censure, suspension, revocation, etc.) been taken against this
individual by your Board or any other state agency?
No
Yes (Please attach explanation)
Name of Board Chair/Representative
Title
Date
Signature
NH-6
AUGUST 21