Fillable Home Health, Home Services, Home Nursing Agency Initial Licensure Application (Illinois)

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Home Health, Home Services, Home Nursing Agency Initial Licensure Application (Illinois)

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State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 1 of 24
BEFORE ATTEMPTING TO COMPLETE THE APPLICATION, PLEASE REVIEW THE HOME
HEALTH, HOME SERVICES AND HOME NURSING AGENCY LICENSING RULES AND
REGULATIONS. The rules and regulations can be downloaded from www.dph.illinois.gov under
Laws and Rules. Open and print Illinois Home Health, Home Services and Home Nursing
Agency Code (77 Illinois Administrative Code 245).
Please enclose the completed application and appropriate attachments, accompanied by the
required licensing fee:
$ 25 license fee for single home health license
$1,500 license fee for for home nursing agency
$1,500 license fee for home service agency
$ 500 license fee for home nursing placement agency
$ 500 license fee for home services placement agency
**Applicants for multiple licenses shall pay the higher licensure fees
applicable.
License fee made payable to the Illinois Department of Public Health (check or money order),
should be sent to:
Illinois Department of Public Health
Health Care Facilities and Programs Section
525 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, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 2 of 24
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 "Home Health, Home Service
and Home Nursing 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.
THIS PAGE IS PART OF THE APPLICATION AND MUST BE FILLED OUT WHERE
NECESSARY. PLEASE CHECK ALL APPLICABLE AGENCY TYPES THAT YOU ARE
APPLYING FOR.
FOR OFFICE USE ONLY
License Number
License Number
License Number
Type of Agency
Home Health Agency (complete pages 2, 3, 4, 5, 6, 7, 8, 9,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22)
Home Nursing Agency (complete pages 2, 3, 4, 5, 7, 8, 10, 12, 23, 24)
Home Nursing Placement Agency (complete pages 2, 3, 4, 5, 7, 8, 11, 12, 23, 24)
Home Services Placement Agency (complete pages 2, 3, 4, 5, 7, 8, 11, 12, 23, 24)
Home Services Agency (complete pages 2, 3, 4, 5, 7, 8, 10, 12, 23, 24)
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 3 of 24
GENERAL INFORMATION
Agency Name and Physical Address
Address
ZIP CodeState
City
Agency Name Agency Phone Number
Agency Fax Number
Business Hours a.m. to
E-mail Address
Mailing Address (If agency's mailing address is different from the physical address above)
Address
ZIP CodeStateCity
Illinois County of Agency Headquarters
Fiscal Period (i.e MONTH/DAY)
(MONTH/DAY)
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
agency.
Contact Person
Signature-Agency Administrator/Agency Manager (ORIGINAL ONLY)
Administrator's /Agency Manager's TitleName of Agency Administrator/Agency Manager
Contact Person - Name Phone Number
p.m.
Date Signed
(Select from drop down box)
Days of the Week
to
Must be different than agency phone number
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 4 of 24
Select one TYPE OF ORGANIZATION from the drop down list that corresponds to your agency
(CHOOSE ONE TYPE)
GOVERNMENTAL NON-PROFIT PROPRIETARY
**Note: If organization is a sole proprietorship, the declaration on Page 8 must be completed.
*RA - Registered agent required, see below.
AGENCY INFORMATION
OWNERSHIP
Name of Legal Owner
Street Address
City State ZIP Code
Phone Number
The Illinois Registered 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 Illinois Registered Agent
Street Address
City State
ZIP Code
STOCKHOLDER 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.
Phone Number of Registered Agent
If a corporation or LLC, name of corporation or company
State of incorporation of the company
NAME OF STOCKHOLDER SHARES HELD PERCENTAGE OF SHARES
(Add appropriate response from drop down box)
List the name of corporation or LLC as registered with the Secretary
of State or County-Do not list Shareholder names
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 5 of 24
GOVERNING BODY
Identify the officers of the governing body of your agency. The governing body has legal authority and responsibility for the
conduct of the agency (Section 245.30 of the Illinois Administrative Code 245).
President
Vice President
Secretary
Treasurer
Does the administrator/agency manager have responsibility for more than one Illinois agency? If yes, list additional license
numbers and agency names.
License Number Agency Name
License Number Agency Name
Does the home health agency supervisor have responsibility for more than one Illinois agency?
License Number
License Number
Agency Name
Agency Name
Yes No
Office Name Address State
ZIP Code
NoYes
(Optional)
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 6 of 24
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
HOME HEALTH ONLY
I-Physical TherapyH-Skilled Nursing
J-Speech Therapy
L-Med. Social Worker
Type of Service
M-Home Health Aide
K-Occupational Therapy
I-Physical TherapyH-Skilled Nursing
J-Speech Therapy
L-Med. Social Worker
Type of Service
M-Home Health Aide
K-Occupational Therapy
I-Physical TherapyH-Skilled Nursing
J-Speech Therapy
L-Med. Social Worker
Type of Service
M-Home Health Aide
K-Occupational Therapy
I-Physical TherapyH-Skilled Nursing
J-Speech Therapy
L-Med. Social Worker
Type of Service
M-Home Health Aide
K-Occupational Therapy
I-Physical TherapyH-Skilled Nursing
J-Speech Therapy
L-Med. Social Worker
Type of Service
M-Home Health Aide
K-Occupational Therapy
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 7 of 24
GEOGRAPHIC SERVICE AREA
Identify the counties or portions of counties where the home health, home service, home nursing agency, home services
placement agency, home nurse placement 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. It is recommended for initial licenses to start with 3-5 counties. Additional
counties may be requested to be added the agency's service area after the agency is operational.
County County
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 8 of 24
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. Check NA if not applicable.
PLEASE CHECK ONLY ONE BOX
PURSUANT TO SECTION 16 OF THE ILLINOIS ADMINISTRATIVE PROCEDURES ACT, THE LICENSEE IS REQUIRED
TO ANSWER THE FOLLOWING:
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.
NA
Licensee Signature Date
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 9 of 24
LICENSED OR REGISTERED EMPLOYEES. List ALL licensed, certified and contractual employees. List
at least ONE contracted employee for each applicable specialty (PT, OT, SP, or MSW). FOR HOME
HEALTH AIDE PROVIDE INITIALS OF EMPLOYEE. If home health aide services are provided by Registered
Nurses or Licensed Practical Nurses, please indicate by placing a pound sign (#) in front of the initials of the
person providing the services.
F/T=Full Time, P/T=Part Time and Contract=Contractual Employees. PLEASE SUBMIT COPIES OF
LICENSES FOR PROFESSIONAL STAFF (Staff Nurses, PT/OT/ST, etc.)
Job Title/Name License Number
F/T P/T
Administrator Name
Agency Supervisor Name
Please copy and attach additional pages as needed.
Contract
Expiration Date
HOME HEALTH AGENCY ONLY
Job Title/Name License Number Expiration Date
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 10 of 24
HOME SERVICES/HOME NURSING ONLY
Job Title License Number
F/T P/T
Agency Manager Name
Contract
Expiration Date
LICENSED OR REGISTERED EMPLOYEES. List ALL licensed, certified and contractual employees.
F/T=Full Time, P/T=Part Time and Contract=Contractual Employees. FOR CERTIFIED NURSE AID,
HOMEMAKER, PROVIDE INITIALS OF EMPLOYEE.
Nursing Supervisor (For Home Nursing Only)
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 11 of 24
List ALL licensed, certified registry persons. FOR HOMEMAKER OR CERTIFIED NURSE AIDE, LIST INITIALS OF
REGISTRY PERSON.
HOME NURSING/HOME SERVICES PLACEMENT ONLY
Job Title License Number
Agency Manager Name
Expiration Date
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 12 of 24
Please check the types of revenue sources of income of the agency:
Sources of Revenue
Local Funds
Local Health Department
Medicare Parts A & B (Home Health Only)
Government Funds
Medicaid
Other Government Funds
Other Funds
Self-Pay
HMO/PPO
Commercial Insurance
Other Revenue
X Indicates that an attachment is required for submission with application for the specific
license type. Administrative Code citing referenced in parenthesis.
Home Health Home Nursing Home Services
Home Nursing
Placement
Home Services
Placement
Fee Schedule
(245.90a)3)g)
X X X X X
Sample Client
Contract
X
(245.220)
X
(245.220)
X
(245.225)
X
245.225
Sample Placed
Worker Contract
X
(245.212)
X
(245.214)
Affiliation
Agreements
X Optional Optional
List of Services/
Scope of Work
x
(245.210a)
Description of
Services
(Please See Below)
X X X X X
All Agencies provide a description of the services to be provided for each license type you are applying
for: 245.90a)3)C)
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 13 of 24
HOME HEALTH AGENCY ONLY
Attachment A - Administrator Qualification Review Form
Address
ZIP Code StateCity
Home Health Agency Name
Middle InitialFirst NameLast Name
Address
ZIP Code StateCity
Administrator Information
Daytime Phone Number
Check one of the following categories. Section 245.20 "Home Health Agency Administrator" requires that the administrator
must be one of the following:
Indicate the highest educational level obtained:
High School ADN Diploma R.N.
B.S.N.
B.A. B.S. Master's Doctorate M.D.
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of College
Address of College
ZIP Code StateCity
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 Registered Nurse
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 660.310
Individual with at least one year supervisory or administrative experience in home health care or in a related health program
Extension
Name of College
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 14 of 24
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 IF APPLICABLE. YOUR CURRENT EMPLOYER MUST BE THE AGENCY
IDENTIFIED IN THIS APPLICATION. Please also include a letter of intentions with this application (i.e.
the applicant must write a letter stating that if he/she will be working part time elsewhere, as well as for
this agency, both agencies are aware of the situation, and it presents no conflict of interest).
Describe your relevant work experience for the last five years.
(1) List your most recent position with THIS AGENCY FIRST and work backward.
(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 the names, addresses and telephone numbers of organizations.
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 Previous Employer
ZIP Code StateCity
Duties
Ending (month and year)
Starting (month and year)
Total Hours Worked WeeklyEnding (month and year)
Attachment A - Administrator Qualification Review Form Page 2
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 15 of 24
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)
Attachment A -Administrator Qualification Review Form Page 3
Signature of Applicant (Original Only)
Date Signed
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 16 of 24
HOME HEALTH AGENCY ONLY
Attachment B - Agency Supervisor Qualification Review Form
Address
ZIP CodeStateCity
Home Health Agency Name
Middle InitialFirst NameLast Name
Address
ZIP CodeStateCity
Agency Supervisor Information
Daytime Phone Number (include area code and extension)
Section 245.30 requires that the agency supervisor must be a Registered Nurse.
Indicate the highest educational level obtained:
ADN Diploma R.N. B.S.N. B.A. B.S. Master's 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.
Section 245.30 of the 77 Illinois Administrative Code requires this position to be filled by an individual who is a registered nurse who has
completed a baccalaureate degree program and has at least one year of nursing experience as a Bachelor of Science of Nursing; or a
registered nurse without a baccalaureate degree, who has at least three years of nursing experience as a Registered Nurse 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 registered 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, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 17 of 24
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 IF APPLICABLE. YOUR CURRENT EMPLOYER MUST BE THE AGENCY
IDENTIFIED IN THIS APPLICATION. Please include an intentions letter with this application (the agency
supervisor position is required to be full time upon licensure. Provide documentation that the applicant is resigning
present employment upon licensure, or if working part time elsewhere, provide documentation that the applicant's
other employment is outside the agency's hours of operation (nights/weekends).
Describe your relevant work experience for the last five years.
(1) List your most recent position with THIS AGENCY FIRST and work backward.
(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 the names, addresses and telephone numbers of the organization.
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 Previous Employer
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)
Atttachment B-Agency Supervisor Qualification Review Form Page 2
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 18 of 24
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)
Attachment B - Agency Supervisor Qualification Review Form Page 3
Signature of Applicant (Original Only) Date
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 19 of 24
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 Phone Number
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 also should appear on the (licensed or registered employees)
page for Home Health and, check if F/T, P/T or contract.
Applicant Name
HOME HEALTH ONLY - If Applicable
Extension
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 20 of 24
THE FOLLOWING TO BE COMPLETED BY MEDICAL SOCIAL WORKER
Section 245.20 requires that the medical social worker be a licensed social worker/clinical social worker under
the Clinical Social Work and Social Work Practice Act.
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 (if applicable) 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 Work Qualification Review Form Page 2
Name of College
Address of College
Date of Graduation
City State ZIP Code
Specialty Degree
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 21 of 24
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 December 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)
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form Page 3
HOME HEALTH ONLY
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 22 of 24
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 (if applicable)
Signature of Medical Social Worker Applicant (Original Only) Date
Signature of Social Worker Assistant (if applicable) (Original Only)
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form Page 4
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 23 of 24
ALL AGENCIES EXCEPT HOME HEALTH
Attachment E-Agency Manager Qualification Review
If the agency is applying for more than one type of agency, complete an additional Attachment E form for each manager.
Address
City State ZIP Code
Agency Manager Information
Last Name First Name MI
Address
City State ZIP Code
Daytime Phone Number (include area code and extension)
See Section 245.30g for the requirements for the agency manager.
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 IF APPLICABLE.
Previous Employer Name
Address of Previous Employer
City State
ZIP
Code
Starting (month and year) Ending (month and year) Total Hours Worked Weekly
Duties
Choose one:
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency Initial Licensure
Application
Form Number (445103)(revised 6/2017) Page 24 of 24
Attachment E - Agency Manager Review Form Page 2
Have you ever been convicted of a criminal offense?
Are there any pending or administratively resolved issues concerning your professional license in Illinois or in another state?
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 details in detail, including the state of administrative action (Section
245.130b)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.
Signature of Applicant/Agency Manager
(Original Signature)
Date
Yes No
Yes
No
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Home Health, Home Services, Home Nursing Agency Initial Licensure Application (Illinois)

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Completed 15 September 2020

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