Fillable Home Health, Home Services, Home Nursing Agency Renewal/Change of Ownership Licensure Application (Illinois)

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Home Health, Home Services, Home Nursing Agency Renewal/Change of Ownership Licensure Application (Illinois)

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State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 1 of 27
The completed application and appropriate attachments, accompanied by the required 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
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 home nursing agency
$1,500 license fee for home services agency
$ 500 license fee for home nursing placement agency
$ 500 license fee for home services placement agency
DUE DATE IS 60 DAYS PRIOR TO THE EXPIRATION OF THE
CURRENT LICENSE
NOTE: Please 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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 2 of 27
THIS PAGE IS PART OF THE APPLICATION AND MUST BE FILLED OUT WHERE NECESSARY.
PLEASE CHECK ALL APPLICABLE AGENCY TYPES FOR WHICH YOU ARE SUBMITTING AN
APPLICATION.
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 Services 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.
CHECK THE TYPE OF AGENCY THIS APPLICATION IS BEING COMPLETED FOR. COMPLETE ONLY THE PAGES
LISTED NEXT TO THE AGENCY TYPE. FAILURE TO COMPLETE ONLY THE REQUIRED PAGES COULD RESULT
IN A DELAY IN PROCESSING THE APPLICATION AND ISSUANCE OF THE LICENSE.
FOR OFFICE USE ONLY
License Number
License Number
License Number
Home Health Agency (complete pages 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25)
Home Nursing Agency (complete pages 2, 3, 4, 5, 6, 8, 9, 11, 13, 15, 26, 27)
Home Nursing Placement Agency (complete pages 2, 3, 4, 5, 6, 8, 9, 11, 14, 15, 26, 27)
Home Services Placement Agency (complete pages 2, 3, 4, 5, 6, 8, 9,11, 14, 15, 26, 27)
Home Services Agency (complete pages 2, 3, 4, 5, 6, 8, 9, 11, 13, 15, 26, 27)
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 3 of 27
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.
GENERAL INFORMATION
Agency Name and Physical Address
Address
ZIP Code State
City
Agency Name Agency Phone
Agency Fax
Business Hours a.m. to
p.m.
Days of the Week
E-mail Address
Mailing Address (If agency's mailing address is different from the physical address above.)
Address
ZIP Code StateCity
Illinois County of Agency
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 Title
Phone Number
License Number
Medicare Number
Renewal
Change of Ownership
Name of Contact Person
Name of Agency Administrator/Agency Manager
Date Signed
License Expiration Date
License Number
License Number
to
Must be different than agency phone number
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 4 of 27
BRANCH OFFICE INFORMATION
Does your agency maintain branch offices?
Yes
No
Address/City County ZIP Code
Phone Number Date Branch
Location Approved*
*Is this a change in information from the previous year's application?
Yes No
OWNERSHIP
Select one TYPE OF ORGANIZATION from the drop down list that corresponds to the type of agency you have.
GOVERNMENTAL NON-PROFIT PROPRIETARY
*RA - Registered agency required, see below.
**Note: If organization is a sole proprietorship, the declaration on Page 13 must be completed.
AGENCY INFORMATION
Name of Legal Owner
Street Address
City State ZIP Code
Phone Number
Did the type of organization change from previous year's application?
Yes No
If yes, list the location of each branch office.
(CHOOSE ONE TYPE)
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 5 of 27
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 agency's ownership papers as registered, contact the Secretary of State's Office to identify the
agency's registered agent of record. www.ilsos.gov/corporatellc/
ILLINOIS REGISTERED AGENT
Name of Illinois Registered Agent
Street Address
City State
ZIP Code
Phone Number
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. For any change in stock holder from the previous renewal submit a copy of
the document to support this change.
If a corporation or LLC, name of corporation or company
State of incorporation of company
Name of Shareholder Shares Held Percentages of Shares
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 6 of 27
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
Office Name of Individual
Yes No
Yes No
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 7 of 27
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
H-Skilled Nursing I-Physical Therapy
J-Speech Therapy
L-Med. Social Worker
Type of Service
M-Home Health Aide
K-Occupational Therapy
M-Home Health Aide
H-Skilled Nursing I-Physical Therapy
J-Speech Therapy
L-Med. Social Worker
Type of Service
K-Occupational Therapy
M-Home Health Aide
H-Skilled Nursing I-Physical Therapy
J-Speech Therapy
L-Med. Social Worker
Type of Service
K-Occupational Therapy
M-Home Health Aide
H-Skilled Nursing I-Physical Therapy
J-Speech Therapy
L-Med. Social Worker
Type of Service
K-Occupational Therapy
M-Home Health Aide
H-Skilled Nursing I-Physical Therapy
J-Speech Therapy
L-Med. Social Worker
Type of Service
K-Occupational Therapy
HOME HEALTH AGENCY ONLY
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 8 of 27
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 and distinguish if the counties are different for
each license. If the agency is approved to serve only a portion of a county, please place an asterisk (*) in front of the
county. Include all approved counties even if no patients were served in a particular county in the last fiscal year if you wish
to retain the county in your service area. Please do not include radius miles as a description of the service area. All service
areas must be contiguous.
County County
TOTAL NUMBER OF DUPLICATED PATIENTS SERVED OUTSIDE OF ILLINOIS:
See page 11 for definition of duplicated patients.
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 9 of 27
Please check the types of revenue sources of income of this agency.
Sources of Revenue
Local Funds
Government Funds
Other Funds
Local Health Department
Medicare Parts A & B (Home Health only)
Medicaid
Other Government Funds
Self-pay
HMO/PPO
Other Revenue
Commercial Insurance
Home Services/Home Nursing/Home Services Placement/Home Nursing Placement
Provided a copy of the current contract per 245.220 for Home Services/Home Nursing
Provided a copy of the current contract per 245.225 for Home Service Placement/Home
Nursing Placement
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 10 of 27
Services Provided
Patients by Service
Record the total number of patients, including duplicated* patients, receiving care in Illinois, in each category of service
during the last fiscal period. A duplicated patient could simultaneously be receiving multiple services.
COLUMN ONE - Record the total number of patients who received each service in Illinois.
COLUMN TWO - Record the total number of visits for each service provided in Illinois.
*A duplicated patient is an individual receiving service from a home health agency who is subsequently discharged and
later readmitted during the same reporting fiscal period. Such a patient is to be considered a new admit. A patient should
be counted each time he/she is readmitted during the same reporting period.
Type of Service Total Number of Patients
and Duplicated Patients by
Service
Total Number of
Visits
Skilled Nursing
Physical Therapy
Speech Therapy
Occupational Therapy
Medical Social Work
Home Health Aide
Other
TOTAL
Only patients receiving home health services
HOME HEALTH AGENCY ONLY
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 11 of 27
THIS PAGE IS TO BE COMPLETED BY ALL AGENCIES
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 N/A if not applicable. PLEASE CHECK
ONLY ONE BOX. Sign and date below selection.
DateLicensee Signature
Home Health Home Services Home Nursing Agency
# of admissions of most recent fiscal period
# of discharges of most recent fiscal period
# of admissions for patients 65 or older
at time of admission of most recent fiscal period
patient/client census on last day of most recent
fiscal period
# of clients placed with workers in past fiscal period
Home Services
Placement Agency
Home Nursing
Placement Agency
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.
N/A
Record the total number of clients, including duplicated clients, for the admissions and discharges during the
fiscal (reporting) period. Do not include client services exclusively under the Community Care Program (CCP),
Department of Human Services or Veteran Affairs. If there are no clients in any section, please indicate with a zero.
*A duplicated patient or client is an individual receiving services from an agency who is subsequently discharged and
later readmitted during the same reporting fiscal period. Such an individual is to be considered a new admission. An
individual should be counted each time he/she is readmitted during the same reporting period.
*A duplicated placement is an individual receiving placement services during the reporting fiscal year. Such an
individual is to be counted as many times as he/she receives a placement service during the same reporting period.
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 12 of 27
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 , DO NOT INCLUDE SOCIAL SECURITY NUMBER. 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.
Job Title/Name License Number
F/T P/T
Administrator Name
Agency Supervisor Name
Please copy and attach additional pages as needed.
Expiration Date
HOME HEALTH AGENCY ONLY
Job/Title
License Number Expiration Date
Contract
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 13 of 27
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 OR
HOMEMAKER, PROVIDE INITIALS OF EMPLOYEE, DO NOT INCLUDE SOCIAL SECURITY NUMBER.
Nursing Supervisor (For Home Nursing Only)
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 14 of 27
List ALL licensed, certified registry persons. FOR HOMEMAKER OR CERTIFIED NURSE AIDE, PROVIDE 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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 15 of 27
AFFIDAVIT
Please include a copy of each of the following employee's current Illinois license, if applicable.
This is to attest that the following named staff members serve in the position indicated. Please be sure to
check the change/no change box for each position.
Home Health
Administrator
Name of Administrator
Social Worker
Social Worker's
Assistant
Name of Social Worker
Name of Social Worker's Assistant
Authorized Agent Signature
Attached are the completed qualification review forms and current Illinois license(s) for the above
change(s).
Change No Change
Change
Change
No Change
No Change
HOME HEALTH/HOME SERVICES/HOME NURSING AGENCY ONLY
Please remember to include a copy of the employee's current Illinois license. If you have submitted a change during the
reporting year and received an approval letter from the Illinois Department of Public Health, it is not considered a change
with this application.
Home Health
Agency Supervisor
Change
No Change
Name of Agency Supervisor
It is NOT necessary to complete a qualification review form if there has been no change.
Home Services/Home
Nursing
Agency Manager
Name of Agency Manager
Change No Change
Home Health
Home Services/Home
Nursing
Authorized Agent Signature
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 16 of 27
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 17 of 27
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 (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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 18 of 27
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 19 of 27
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 Bachelors of Science of Nursing; or a
registered nurse without a baccalaureate degree, who has at least three years of nursing experience as an 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 Registered Nurse
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 20 of 27
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 a letter of intentions with this application (the agency
supervisor position is required to be full time. Provide documentation that the applicant is resigning
present employment, or if working part time elsewhere, provide documentation that the applicant's other
employment is outside the agency's hours of operation).
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 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
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 21 of 27
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 22 of 27
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form
Address
ZIP Code
StateCity
Home Health Agency Name
Middle InitialFirst NameLast Name
Address
ZIP Code
StateCity
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 F/T, P/T or contract.
HOME HEALTH ONLY - If Applicable
Extension
Medical Social Worker Information
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 23 of 27
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 24 of 27
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 AGENCY ONLY
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 25 of 27
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
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 26 of 27
ALL AGENCIES EXCEPT HOME HEALTH
Attachment E-Agency Manager Qualification Review Form
If the agency is applying for more than one type of agency, complete an additional Attachment E form for each manager.
Home Nursing Agency Name
Home Service Agency Name
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.
Describe your relevant work experience.
Previous Employer Name
Address of Previous Employer
City State ZIP Code
Starting (month and year) Ending (month and year) Total Hours Worked Weekly
Duties
State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Form Number (445104) (revised 6-2017) Page 27 of 27
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 (Original Only) Date
ATTACH A COPY OF YOUR CURRENT ILLINOIS LICENSE, IF APPLICABLE
Yes No
Yes No
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Home Health, Home Services, Home Nursing Agency RenewalChange of Ownership Licensure Application (Illinois)

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Completed 15 September 2020

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