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Assisted Living Licensure Application Materials
After you have downloaded and finalized your application, upload the completed application and addendum forms to the Facility and Provider Licensing System.
On this page:
Provisional Assisted Living (with Dementia Care) License Application (PDF)
- Assisted Living Licensure Application Addendum: Building Information (PDF)
- Assisted Living Licensure Application Addendum: Additional Direct or Indirect Owner Information (PDF)
- Assisted Living Licensure Application Addendum: New Construction Information (PDF)
- Assisted Living Licensure Application Addendum: Additional Managerial Officials and Controlling Individuals Information (PDF)
Uniform Disclosure of Assisted Living Services and Amenities (UDALSA) (PDF)
"Applicant" means an individual, legal entity, or other organization that has applied for licensure under this chapter.
The requirements that will be necessary for the application process are found in statute 144G.12.
MDH will acknowledge receipt of the application in an email to the applicant. Incomplete or inaccurate applications may be rejected and will be sent back to the applicant (Minn. Stat. sect. 144G.15(a)(1)). Once MDH determines it has all required application information, signatures, and attachments, MDH will contact the applicant to request payment of the application fee.
The license application fee is non-refundable (Minn. Stat. sect. 144G.12, Subd. 3(b)).
Related Statutes: 144G.08 Subd. 4 & 55 144G.12 144G.15 144G.191
The license is valid for 1 year.
Yes. It is called a provisional license. After the application is completed and approved, the applicant will receive a provisional license. Once they begin to provide services to a resident, they must notify the department within two days. The department must conduct an initial survey of the provisional licensee within one year. If the provisional licensee has a satisfactory survey, they will be granted the assisted living (with dementia care) license. See Ch. 144G.09 MN Statutes and Ch. 144G.16 MN Statutes. (This does not apply to conversion applicants).
Choose this option: V (000)
You may write "not applicable" in the space.
A Property Identification Number (PIN) is a number assigned to parcels of real estate property by the tax assessor of a particular jurisdiction for purposes of identification and record keeping. A PIN may also be referred to as a Property Tax ID Number.
You can request a replacement copy by calling the IRS Business and Specialty Tax Line. The phone number is (800) 829-4933, and the line is open from 7 a.m. to 7 p.m., taxpayer local time, Monday through Friday.
The IRS should send the applicant a confirmation when the request is submitted. If the applicant does not receive the form prior to applying for licensure then they can submit that confirmation and follow up with the form when it is received.
- Applying for a Provisional Assisted Living License (YouTube: 2:41)
- How to Apply for an Assisted Living Provisional License (YouTube: 3:54)
- Information Needed Prior to Application (YouTube: 2:58)
- Difference between assisted living facility and assisted living facility with dementia care licenses (YouTube: 3:39)
Filling out the application:
- Assisted Living Campus (YouTube: 2:04)
- Authorized Agent (YouTube: 1:41)
- Building Construction Type (YouTube: 0:46)
- Clinical Nurse Supervisor (YouTube: 1:21)
- Contact Information (YouTube: 1:52)
- Controlling Individuals (YouTube: 3:08)
- Direct/Indirect Owners (YouTube: 3:07)
- Kitchen/Food Prep Areas (YouTube: 1:33)
- Licensed Assisted Living Director (YouTube: 2:28)
- Licensed Resident Capacity (YouTube: 2:36)
- Managerial Official / Agent (YouTube: 1:48)
- Org Chart and Organizational Description (YouTube: 2:44)
- Physical Environment - Provisional licenses (YouTube: 4:23)
- Submitting a Provisional Application and Attachments (YouTube: 3:59)
- Uniform Disclosure of Assisted Living Services and Amenities (YouTube: 2:01)