South Carolina Board of Long Term Health Care Administrators

Applications/Forms

Online Applications

Below are the links to the forms for the applicable applications. These forms will need to be downloaded, filled out and submitted with the application or as instructed. You may submit the forms in the Uploads sections of the application or mail in to our office. Electronic applications allow you to make payment via Visa/Mastercard or e-check.

1. Please review and select the appropriate link to download the form(s) before beginning the electronic application.

• Signature Affidavit
• CRCA Employment Reference Form
• NHA Employment Reference Form
• Character Reference Form
• License Verification Form

2. Click here to begin the electronic application

NHA Administrator-In-Training Forms

AIT Candidate Forms:

• NHA AIT Candidate Application Packet
• NHA AIT Candidate Monthly Report Packet
• NHA AIT Final Report
• CRCFA AIT Candidate Application Packet
• CRCFA AIT Candidate Monthly Report Packet
• CRCFA AIT Final Report

AIT Preceptor Forms:

• AIT Preceptor Directory
• AIT Preceptor Application

Paper Applications

Initial Licensure

• Nursing Home Administrator Licensure Application Packet
• Community Residential Care Facility Administrator Licensure Application Packet
• DUAL: NHA/CRCFA Administrator Licensure Application

Reactivation of License

• Reactivation of Inactive License Application
• Reactivation of Retired License Application

Renewals

• 2019-2020 Renewal Application
• AIT Preceptor Renewal Application
• AIT Candidate Renewal Application

Continuing Education

• Continuing Education Course Application - Administrator Submission
• Continuing Education Course Application - Sponsor Submission
• SC Approved Continuing Education

Other Forms

• Employment Change Notification Form
• Name/Address Change Form
• Licensee List Request