Fillable Home Health Agency Initial Licensure Application (Lake Land College)

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Home Health Agency Initial Licensure Application (Lake Land College)

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  • 66 check-boxes
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State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 1 of 21
BEFORE ATTEMPTING TO COMPLETE THE APPLICATION, PLEASE REVIEW THE HOME
HEALTH LICENSING RULES AND REGULATIONS. The rules and regulations can be
downloaded from www.idph.state.il.us under "A" Administrative Rules, "Administrative Rules
Only". Open and print Illinois Home Health Agency Code (77 Illinois Administrative Code 245).
The completed application and appropriate attachments, accompanied by the required $25
license fee made payable to the Illinois Department of Public Health (check or money order),
should be sent to:
Illinois Department of Public Health
Division of Financial Services
Validation Unit
535 W. Jefferson St., Fourth Floor
Springfield, IL 62761-0001
NOTE: Retain a copy of the application for future reference.
IF YOU DO NOT TYPE THE APPLICATION USING ADOBE AND CHOOSE TO COMPLETE THE APPLICATION IN
WRITING, BE SURE TO MAKE NOTE OF DROP-DOWN BOXES TO PROPERLY COMPLETE THE APPLICATION.
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 2 of 21
IMPORTANT NOTICE - Pursuant to the Home Health Agency Licensing Act (210 ILCS 55/1 et seq.)
and the rules and regulations of the Illinois Department of Public Health, titled "Illinois Home Health
Agency Code" (77 Ill. Adm. Code 245), this state agency is requesting disclosure of information that
is necessary to accomplish the statutory purpose as outlined under the act and the attendant rules.
Disclosure of this information is mandatory. This form has been approved by the Forms Management
Center.
General Information
AGENCY NAME AND MAILING ADDRESS
Address
Zip CodeState
City
Agency Name Agency Telephone number
Agency Fax number
Business Hours am to
Days of Week
E-Mail Address
FACILITY ADDRESS (If agency's physical location is different from the mailing address above)
Address
Zip CodeStateCity
ILLINOIS COUNTY OF AGENCY HEADQUARTERS
FISCAL YEAR DATA BEGINNING
, 20 AND ENDING , 20
AFFIDAVIT OF AGREEMENT
The data contained in this application has been reviewed by me and is accurate to the best
of my knowledge. I will comply with all rules and regulations governing the licensing of this
home health agency.
CONTACT PERSON
Signature-Agency Administrator (ORIGINAL ONLY)
Administrator's TitleName of Agency Administrator
Contact Person - Name Phone Number
pm
Date Signed
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 3 of 21
Select the TYPE OF ORGANIZATION that corresponds to the type of agency you have.
GOVERNMENTAL NON-PROFIT PROPRIETARY
**Note: If organization is a sole proprietorship, the declaration on page 7 must be completed.
*RA - Registered agent required, see below.
AGENCY INFORMATION
Ownership
Name of Legal Owner
Street Address
City State Zip Code
Telephone Number
The Illinois Regsitered agent's address must be in Illinois. If you are unable to identify the registered agent by name, or have
misplaced a copy of the agent's ownership papers as registered, contact the Secretary of State's office to identify the
registered agent of record.
ILLINOIS REGISTERED AGENT
Name of Iliniois Registered Agent
Street Address
City State
Zip Code
STOCKHOLDERS' INFORMATION
If the organization is a corporation, list the number of shares held and the percentage of total shares held by shareholders
with more than 5 percent of common stock or by the top five stockholders, whichever is less.
Telephone Number of Registered Agent
If a corporation or LLC, name of corporation or company
State of incorporation of company
NAME OF STOCKHOLDER SHARES HELD PERCENTAGE OF SHARES
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 4 of 21
GOVERNING BODY
Identify the officers of the governing body of your home health agency. The governing body has legal authority and
responsibility for the conduct of the home health agency (Section 245.30 of the Illinois Administrative Code 245)
PRESIDENT
VICE PRESIDENT
SECRETARY
TREASURER
Does the administrator have responsibility for more than one Illinois parent agency?
If "Yes", list additional parent license numbers and agency names.
License Number Agency Name
License Number Agency Name
Does the agency supervisor have responsibility for more than one Illinois parent agency?
License Number
License Number
Agency Name
Agency Name
Yes No
Yes No
OFFICE NAME ADDRESS STATE ZIP Code
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 5 of 21
AGENCY CONTRACTS (add additional copies of this form if necessary)
Please note that SKILLED NURSING may not be contracted unless it is to cover vacations of regular staff or for specialized
skills not routinely offered. SKILLED NURSING must be directly provided by the agency plus ONE OTHER RECOGNIZED
SERVICE in order to qualify as a home health agency pursuant to Illinois law. If you use contracted SKILLED NURSING,
please provide rationale.
Legal Name and Address of Organization
Type of Service
Type of Service
Type of Service
Type of Service
Type of Service
H-Skilled Nursing
H-Skilled Nursing
H-Skilled Nursing
H-Skilled Nursing
H-Skilled Nursing
I-Physical Therapy
I-Physical Therapy
J-Speech Therapy K-Occupational Therapy
L-Medical Social Work M-Home Health Aide
I-Physical Therapy
I-Physical Therapy
I-Physical Therapy
J-Speech Therapy
J-Speech Therapy
J-Speech Therapy
J-Speech Therapy
K-Occupational Therapy
K-Occupational Therapy
K-Occupational Therapy
K-Occupational Therapy
L-Medical Social Work
L-Medical Social Work
L-Medical Social Work
L-Medical Social Work
M-Home Health Aide
M-Home Health Aide
M-Home Health Aide
M-Home Health Aide
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 6 of 21
GEOGRAPHIC SERVICE AREA
Identify the counties or portions of counties where the home health agency intends to serve patients. If you are intending
to serve only a portion of a county, indicate that county with an asterisk (*). All service areas must be contiguous. Please
do not include radius miles as a description of the service area.
Geograhic Service Area
County County
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 7 of 21
SOLE PROPRIETOR DECLARATION
Pursuant to section 16 of the Illinois Administrative Procedures Act, the licensee is required to complete the Sole Proprietor
Declaration page if the organization is set up as a sole proprietorship.
I CERTIFY UNDER PENALTY OF PERJURY THAT I AM NOT MORE THAN 30 DAYS DELINQUENT IN
COMPLYING WITH A CHILD SUPPORT ORDER. FAILURE TO DO SO MAY RESULT IN A DENIAL
OF THE RENEWAL LICENSE. MAKING A FALSE STATEMENT MAY SUBJECT THE LICENSEE TO
CONTEMPT OF COURT.
I AM MORE THAN 30 DAYS DELINQUENT IN COMPLYING WITH A CHILD SUPPORT ORDER.
I CERTIFY UNDER PENALTY OF PERJURY THAT I AM NOT SUBJECT TO ANY CHILD SUPPORT
ORDER.
LICENSEE SIGNATURE DATE
PURSUANT TO SECTION 16 OF THE ILLINOIS ADMINISTRATIVE PROCEDURES ACT, THE LICENSEE IS REQUIRED
TO ANSWER THE FOLLOWING:Text
N/A
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 8 of 21
LICENSED OR REGISTERED EMPLOYEES. List ALL licensed, certified and *contractual employees. List
at least ONE contracted employee by specialty (PT, OT, SP, or MSW). Identify the contracted employees
by an asterisk (*).
If home health aide services are provided by RNs or LPNs, please indicate by placing a pound sign (#) in front of the name of
the person providing the services. For home health aides, list Social Security numbers in the license certification column.
JOB TITLE EMPLOYEE'S NAME LICENSE OR
CERTIFICATION
NUMBER
FULL-TIME
PART-TIME
ADMINISTRATOR
AGENCY SUPERVISOR
SUPERVISING NURSE
Please copy and attach additional pages as needed.
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 9 of 21
Attachment A - Administrator Qualification Review Form
Address
Zip CodeStateCity
HHA Agency Name
Middle InitialFirst NameLast Name
Address
Zip CodeStateCity
Administrator Information
Daytime Telephone number (include area code and extension)
Check one of the following categories. Section 245.20 requires that the administrator must be one of the following:
Indicate the highest educational level obtained
High School ADN Diploma RN BSN
BA BS Masters Doctorate MD
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of college
Address of college
Zip CodeStateCity
Date of graduation Specialty/degree
Name of high school
Address of high school
Zip CodeStateCity
Date of graduation
Please list the high school attended, the address, and date of graduation
Physician RN
City
Address of college
Zip CodeState
Date of graduation Specialty/degree
individual who meets the requirements for a public health administrator as defined in 77 IL Adm. Code 600.310
individual with at least 1 yr. supervisory or administrative experience in home health care or in a related health program.
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 10 of 21
List applicable professional licenses, registrations and/or certifications currently held with the license
number, date of expiration and state that issued the license, registration or certification. Attach a copy
of your current Illinois license. Your current employer must be the home health agency identified in
this application.
Describe your relevant work experience for the last five years.
(1) List your most recent position first and work backward. For INITIAL applications, list the agency to be licensed as
your current employer (upon licensure). Provide intentions at any other positions you may hold, (i.e., resigning
upon licensure, working part-time, if so how many hours per week).
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Describe the administrative and financial functions performed for each position with each agency that qualify you to
function as the administrator of a home health agency.
(4) Include names of organizations, the addresses and telephone numbers.
You may use an additional sheet of paper to complete this section. Resumes are not accepted in lieu of completion of this
portion of the form.
Current Employer Name
Address of Current Employer
Zip CodeStateCity
Starting (month and year)
Total hours worked weekly
Duties
Previous Employer Name
Address of PreviousEmployer
Zip CodeStateCity
Duties
Ending (month and year)
Starting (month and year)
Total hours worked weeklyEnding (month and year)
Attachment A - Administrator Qualification Review Form p.2
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 11 of 21
Previous Employer Name
Address of Previous Employer
Zip CodeStateCity
Duties
Have you ever been convicted of a criminal offense?
Yes No
Are there any pending or administratively resolved issues concerning your professional
license in Illinois or in another state?
Yes No
If you answered “yes” to either or both of the above statements, please describe the criminal offense
and/or the pending or administratively resolved licensure issues in detail, including the state of
administrative action [Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary
for the explanation.
I signify that the information contained in this form is true and correct to the best of my knowledge and
belief. I realize that misrepresentation of this information at any time may be cause for denial of this
application, or future revocation of a license.
Starting (month and year)
Total hours worked weeklyEnding (month and year)
Signature of applicant Date
Attachment A - Administrator Qualificaiton Review Form p.3
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 12 of 21
Attachment B - Agency Supervisor Qualification Review Form
Address
Zip Code w/extensionStateCity
HHA Agency Name
Middle InitialFirst NameLast Name
Address
Zip CodeStateCity
Agency Supervisor Information
Daytime Telephone number (include area code and extension)
Check one, Section 245.30 requires that the agency supervisor must be one of the following:
Indicate the highest educational level obtained
ADN Diploma RN BSN BA BS Masters Doctorate MD
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of college
Address of college
Zip CodeStateCity
Date of graduation Specialty/degree
Name of high school
Address of high school
Zip CodeStateCity
Date of graduation
Please list the high school attended, the address, and date of graduation
Physician
RN
Section 245.30 of the 77 Illinois Administrative Code requires this position to be filled by an individual who is a physician; a
registered nurse who has completed a baccalaureate degree program....and has at least one year of nursing experience as a
BSN; or a registered nurse without a baccalaureate degree, but who has at least three years of nursing experience as an RN
within the last five years (two of those years in a home health agency, a community health program caring for the sick, or a
family centered nursing program in a community health agency). Section 245.20 defines a registerd nurse as a person
currently licensed as an RN under the Illinois Nursing Act.
Address of college
Name of college
Zip CodeStateCity
Date of graduation Specialty/degree
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 13 of 21
List applicable professional licenses, registrations and/or certifications currently held with the license
number, date of expiration and state that issued the license, registration or certification. Attach a copy
of your current Illinois license. Your current employer must be the home health agency identified in this
application.
Describe your relevant work experience for the last five years.
(1) List your most recent position first and work backward. For INITIAL applications, list the agency to be licensed as your
current employer (upon licensure). Provide intentions at any other positions you may hold, (i.e., resigning upon
licensure, working part-time, if so how many hours per week).
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Describe the administrative functions performed for each position with each agency that qualify you to function as the
agency supervisor of a home health agency.
(4) Include names of organizations, the addresses and telephone numbers.
You may use an additional sheet of paper to complete this section. Resumes are not accepted in lieu of completion of
this portion of the form.
Current Employer Name
Address of Current Employer
Zip CodeStateCity
Duties
Previous Employer Name
Address of PreviousEmployer
Zip CodeStateCity
Duties
Starting (month and year)
Total hours worked weeklyEnding (month and year)
Starting (month and year)
Total hours worked weeklyEnding (month and year)
Attachment B - Agency Supervisor Qualification Review Form p.2
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 14 of 21
Previous Employer Name
Address of Previous Employer
Zip CodeStateCity
Duties
Have you ever been convicted of a criminal offense?
Yes No
Are there any pending or administratively resolved issues concerning your professional
license in Illinois or in another state?
Yes No
If you answered “yes” to either or both of the above statements, please describe the criminal offense
and/or the pending or administratively resolved licensure issues in detail, including the state of
administrative action [Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary
for the explanation.
I signify that the information contained in this form is true and correct to the best of my knowledge and
belief. I realize that misrepresentation of this information at any time may be cause for denial of this
application, or future revocation of a license.
Starting (month and year)
Total hours worked weeklyEnding (month and year)
Signature of applicant Date
Attachment B - Agency Supervisor Qualification Review Form p.3
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 15 of 21
Attachment C - Supervising Nurse Qualification Review Form
Address
Zip CodeStateCity
HHA Agency Name
Middle InitialFirst NameLast Name
Address
Zip CodeStateCity
Supervising Nurse Information
Daytime Telephone number (include area code and extension)
Section 245.30 requires that the supervising nurse must be a full-time registered nurse with the licensed/to be licensed
agency.
Indicate the highest educational level obtained
ADN Diploma RN BSN BA BS Masters Doctorate
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of college
Address of college
Zip CodeStateCity
Date of graduation Specialty/degree
Name of high school
Address of high school
Zip CodeStateCity
Date of graduation
Please list the high school attended, the address, and date of graduation
State
Address of college
Zip CodeCity
Date of graduation Specialty/degree
Name of college
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 16 of 21
List applicable professional licenses, registrations and/or certifications currently held with the license
number, date of expiration and state that issued the license, registration or certification. Attach a copy
of your current Illinois license. Your current employer must be the home health agency identified in
this application.
Describe your relevant work experience for the last five years.
(1) List your most recent position first and work backward. For INITIAL applications, list the agency to be licensed as your
current employer (upon licensure). Provide intentions at any other positions you may hold, (i.e., resigning upon
licensure, working part-time, if so how many hours per week).
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Include names of organizations, the addresses and telephone numbers.
You may use an additional sheet of paper to complete this section. Resumes are not accepted in lieu of completion of
this portion of the form.
Current Employer Name
Address of Current Employer
Zip CodeStateCity
Starting (month and year) Total hours worked weekly
Duties
Previous Employer Name
Address of PreviousEmployer
Zip CodeStateCity
Duties
Ending (month and year)
Total hours worked weeklyStarting (month and year) Ending (month and year)
Attachment C - Supervising Nurse Qualification Review Form p.2
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 17 of 21
Previous Employer Name
Address of Previous Employer
Zip CodeStateCity
Duties
Have you ever been convicted of a criminal offense?
Yes No
Are there any pending or administratively resolved issues concerning your professional
license in Illinois or in another state?
Yes No
If you answered “yes” to either or both of the above statements, please describe the criminal offense
and/or the pending or administratively resolved licensure issues in detail, including the state of
administrative action [Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary
for the explanation.
I signify that the information contained in this form is true and correct to the best of my knowledge and
belief. I realize that misrepresentation of this information at any time may be cause for denial of this
application, or future revocation of a license.
Total hours worked weeklyStarting (month and year) Ending (month and year)
Signature of applicant Date
Attachment C - Supervising Nurse Qualification Review Form p.3
click to sign
signature
click to edit
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 18 of 21
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form
Address
Zip CodeStateCity
HHA Agency Name
Middle InitialFirst NameLast Name
Address
Zip CodeStateCity
Daytime Telephone number (include area code and extension)
Attachment D must be completed for each social worker and social work assistant used by your home
health agency, whether directly employed or employed by contract. Section 245.20 of the 77 Illinois
Administrative Code 245 requires that the medical social worker be a licensed social worker/clinical social
worker under the Clinical Social Work and Social Work Practice Act.
Before forwarding Attachment D to the social worker for completion, please fill in the name, address and
city of your home health agency at the top of the form.
The person(s) completing Attachment D should also appear on page 21 (Licensed or Registered
Employees) and, if contracted, an asterisk should be placed before the name(s).
Your home health agency application will not be considered complete until Attachment D is completed
correctly, signed and dated, and the relevant starting/ending dates of employment and total weekly hours worked
for each employment is indicated.
If you have any questions regarding this form, please contact the Illinois Department of Public Health,
Division of Health Care Facilities and Programs, Central Office Operations Section, 525 W. Jefferson St.,
Fourth Floor, Springfield,IL 62761; or telephone 217-782-7412. The Department's TTY number is
800-547-0466, for use by the hearing impaired. The Division's fax number is 217-782-0382.
Applicant Name
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 19 of 21
THE FOLLOWING TO BE COMPLETED BY MEDICAL SOCIAL WORKER
Section 245.20 requires that the medical social worker must be a licensed social worker/clinical social worker under the
Clinical Social Work and Social Work Practice Act and have one year of social work experience in a health care setting.
Describe your relevant work experience to meet the requirements of Section 245.20
Employer Name
Address of Employer
Zip CodeStateCity
Duties
Employer Name
Address of Employer
Zip CodeStateCity
Duties
List applicable professional licenses, registrations and/or certifications currently held. Attach a copy of your
current Illinois license.
IF YOU ARE A MEDICAL SOCIAL WORKER, PROCEED TO THE SIGNATURE BLOCK AND SIGN AT THE BOTTOM
OF PAGE FOUR.
Date MSW degree awarded Date of initial license
Expiration date of current license State of Issuance
Total hours worked weeklyStarting (month and year) Ending (month and year)
Total hours worked weeklyStarting (month and year) Ending (month and year)
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form p.2
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 20 of 21
THE FOLLOWING SECTION MUST BE COMPLETED BY THE SOCIAL WORK ASSISTANT
Section 245.20 requires that the social work assistant have a baccalaureate degree in social work, psychology, sociology
or related field and at least one year of social work experience in a health care setting. For persons initially licensed by a
state or seeking initial qualifications as a social work assistant prior to 12/31/1977 refer to 77 Illinois Administrative Code.
Address of college
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of college
Zip CodeStateCity
Date of graduation Specialty/degree
Zip Code
Describe your relevant work experience to meet the requirements of Section 245.20
Employer Name
Address of Employer
Zip CodeStateCity
Duties
Employer Name
Address of Employer
StateCity
Duties
Total hours worked weeklyStarting (month and year) Ending (month and year)
Total hours worked weeklyStarting (month and year) Ending (month and year)
Address of college
Name of college
Zip CodeStateCity
Date of graduation Specialty/degree
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form p.3
click to sign
signature
click to edit
State of Illinois
Illinois Department of Public Health
Home Health Agency Initial Licensure Application
Form Number (445103)
Page 21 of 21
I signify that the information contained in this form is true and correct to the best of my knowledge and
belief. I realize that misrepresentation of this information at any time may be cause for denial of this
application, or future revocation of a license.
Section 245.40 requires a social work assistant to be under the supervision of a social worker (social worker as defined
in Section 245.20). Both social work assistant and supervising licensed social worker should complete page 1 of
Attachment D.
Name of licensed social worker providing supervision
Signature of applicant Date
Signature of social worker assistant (if applicable)
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form p.4
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Home Health Agency Initial Licensure Application (Lake Land College)

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Completed 14 September 2020

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