TX HHS Form 5535. Reciprocity Licensure Questionnaire

The TX HHS Form 5535, Reciprocity Licensure Questionnaire, is a crucial document for individuals seeking to obtain licensure as a Nursing Facility Administrator (NFA) in the state of Texas. This form helps solve the problem of verifying an applicant's qualifications and experience in order to grant reciprocity licensure.

The questionnaire consists of two sections: Applicant Information and State Licensed In. The first section requires applicants to provide personal information, including their name, social security number, email address, and phone number. Additionally, applicants must disclose their previous employment history, including the names of employers, dates of employment, and whether they were administrators at these facilities.

The second section is completed by the state where the applicant is currently active, providing information on the applicant's current licensure status, basis for licensure, internship completion date, and number of hours completed. The form also inquires about the applicant's Health Services Executive (HSE) qualification and whether they have had a license or HSE qualification revoked in any state. This questionnaire must be submitted to [email protected] for processing.