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Government of the District of Columbia
Department of Health
Health Regulation and Licensing Administration (HRLA)
899 North Capitol Street, N.E.; 1st Floor
Washington, DC 20002
APPLICATION FOR
NURSE STAFFING AGENCY LICENSE
Thank you for your desire to provide Nurse Staffing Agency (NSA) services in the District of Columbia.
We look forward to you providing expedient and professional services to District residents. Please review
the instructions carefully and be sure to submit all of the required documents. If you require any
assistance with this process, contact Gayle Dugger at [email protected] or by calling (202) 442-4732.
Applying for:
Initial License
Renewal
LICENSURE FEE
Initial License Fee: $1,000 Renewal Fee: $500 Renewal Late Fee: $100
PAYMENT INSTRUCTIONS
Payable by: Check or Money Order to DC Treasurer
Mail to: Intermediate Care Facilities
P.O. Box 37804
Washington, D.C. 20013
Walk-in Address: Department of Health
Health Regulation and Licensing Administration
899 North Capitol Street, NE, 1
st
Floor
Washington, D.C. 20002
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ATTACHMENTS
Submit all of the following documents along with a signed copy of your application.
Submitting an incomplete application will impact the determination for licensure.
Disclosure of Ownership and Control Interest Form
Clean Hands
Certificate of Good Standing and Certificate of Trade Name Registration
Copy of Certificate of Good Standing as a corporation from the Department of Consumer and
Regulatory Affairs, Corporation Division
If the impending licensee is not the agency identified on the Certificate of Good Standing and
is a derivative of a parent company (“doing business as [d/b/a]”), please include the
Certificate of Trade Name Registration from Department of Consumer and Regulatory
Affairs, Corporation Division.
Insurance Verification
Copy of insurance certificate with HRLA added as a certificate holder
As a requirement for renewal, the Intermediate Care Facilities Division (ICFD) must
receive proof of insurance directly from the insurance company. We are NOT
accepting copies from the licensee unless they are accompanied by a receipt of
payment for coverage. All agencies must request that the Department of Health be
listed as a certificate holder on the insurance to make sure that we are notified if any
changes occur during your coverage period.
Agencies located within the District of Columbia
Certificate of Occupancy issued by the District of Columbia Government for premises in which the
office is located.
Agencies located outside of the District of Columbia
Copy of each document certifying the responsible jurisdiction’s approval of the use of that location or
premises as a Nurse Staffing Agency, including all approvals related to zoning, building and fire codes.
Policies and Procedures
Copy of NSA’s policies and procedures (Please note: In order to prevent the disclosure of proprietary
information please place a disclaimer on any information that you consider proprietary.)
Initial License: Submit ALL Required Policies and Procedures.
Renewal: Submit any updates to Policies and Procedures.
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DEMOGRAPHIC INFORMATION
Agency name: ________________________________________________________
Alternative/DBA Name: _______________________________________________
[If applicable]
License number:______________________________________________________
[Please note: This license shall not be valid for use by any other person or persons or at any place other than
that designated in the license Title 22, DCMR, Chapter 49, § 4901.6]
Contact Person:
Name:______________________________________________________________________
Please keep this contact information current. This is the person of record that will be the agency
contact prior to and after the issuance of your licensure.
Professional Title: ___________________________________________________________
Telephone Number: __________________________________________________________
Email Address: _____________________________________________________________
Address: ___________________________________________________________________
___________________________________________________________________________
Supervising Registered Nurse:
Name: _____________________________________________________________________
Professional Title: ___________________________________________________________
DC License Number: _________________________________________________________
Telephone Number: _______________ Email Address: ____________________________
Address: ___________________________________________________________________
___________________________________________________________________________
Owner/Operator of Nurse Staffing Agency:
Name: _____________________________________________________________________
Professional Title: ___________________________________________________________
DC License Number, if applicable: _____________________________________________
Telephone Number: _______________ Email Address: ____________________________
Address: ___________________________________________________________________
___________________________________________________________________________
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AGENCIES LOCATED OUTSIDE OF THE DISTRICT OF COLUMBIA
*Registered Business Office:
Telephone Number: _______________ Email Address: ____________________________
Address: ___________________________________________________________________
___________________________________________________________________________
*Operations Headquarters:
Telephone Number: _______________ Email Address:_____________________________
Address: ___________________________________________________________________
___________________________________________________________________________
Send updated copy of each document certifying the responsible jurisdiction’s approval of the use of that location
or premises as a Nurse Staffing Agency, including all approvals related to zoning, building and fire codes.
AGENCIES LOCATED WITHIN THE DISTRICT OF COLUMBIA
DC Operations Headquarters:
Telephone Number: __________________________________________________________
Email Address: _____________________________________________________________
Certificate of Occupancy #:____________________________________________________
Address: ___________________________________________________________________
___________________________________________________________________________
Send updated Certificate of Occupancy issued by the District of Columbia Government for premises in which the
office is located.
Registered Agent within the District of Columbia:
Registered Agent: ___________________________________________________________
Telephone Number: __________________________________________________________
Email Address: _____________________________________________________________
Address: ___________________________________________________________________
___________________________________________________________________________
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COMPLIANCE QUESTIONS
A. Clean Hands Before Receiving a License or Permit Act of 1996 Certification Form Requirement.
Please read the information below carefully before responding to this yes or no question, as any false
information provided requires that the Department of Health proceed immediately to revoke the License
which you are now renewing, and fine you one thousand dollars ($1,000.00), pursuant to D.C. Official Code
§ 47-2862 (2001).
As of this date, do you owe more than one hundred dollars ($100.00) to the District of Columbia
Government as a result of any of the following: YES ___ NO___
IF YOU ANSWER “YES” TO THIS QUESTION, PLEASE SUBMIT PROOF OF THE ARRANGEMENTS YOU
HAVE MADE TO PAY THE OUTSTANDING DEBT. IF YOU DO NOT HAVE AN APPROVED PAYMENT
SCHEDULE TO PAY THE AMOUNT YOU OWE OR IF NO APPEAL IS PENDING, THE LAW REQUIRES
THAT YOUR APPLICATION BE DENIED.
1. Fines, penalties, or interest assessed pursuant to D.C. Official Code Title 8, Chapter 8 (Litter Control Administration Act of
1985); No Yes
2. Fines or interest assessed pursuant to D.C. Official Code Title 8, Chapter 9 (Illegal Dumping Enforcement Act of 1994);
No Yes
3. Fines, penalties or interest assessed pursuant to D.C. Official Code Title 2, Chapter 18 (Civil infractions Act of 1985);
No Yes
4. Past due taxes; No Yes
5. Past due District of Columbia Water and Sewer Authority service fees; No Yes
6. Failure to file District tax returns. No Yes
The information presented above is in compliance with the requirement to submit with your application for licensure or permit under the Clean
Hands Before Receiving a License or Permit Act of 1996, effective May 11, 1996 (D.C. Law 11-118, D.C. Code § 47-2861 et seq.).
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B. Has another entity suspended, revoked or placed conditions on your license, certification or accreditation as an
NSA?
No Yes If yes, please submit an explanation.
C. Are you currently being or have been (since your last renewal) investigated by any authority for any violation of
state, federal, or local law?
No Yes If yes, please submit an explanation.
D. Have you removed a nurse licensed in DC from your registry as the result of a complaint regarding practice or
substance abuse?
No Yes If yes, please submit name(s) and license number(s) or Social Security
number(s) and the results of your investigation (if not reported previously).
E. Have you made any significant amendments to your Policies and Procedures?
No Yes
If yes, please submit an explanation.
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ATTESTATION
I hereby attest that the information given in this application, including all writings and exhibits attached hereto, is true
and complete to the best of my knowledge. I understand that the making of a false statement on this application, including
all writings and exhibits attached hereto, is punishable by criminal penalties.
__________________________________________________________ ___________________________
SIGNATURE DATE
________________________________________________________ ____________________________
PRINT NAME TITLE
REPORT FRAUD, WASTE, AND ABUSE: To report fraud, waste, or abuse within the District government, contact the
DC Office of the Inspector General’s hotline by phone at 1-800-521-1639 (toll free) or 202-724-TIPS (8477), by email at
[email protected], or by TTY at 711. For additional information, visit the Office of the Inspector General’s website at
oig.dc.gov.
