Home Health and Nursing Agency Initial Licensure Application
This file is the initial licensure application for Home Health, Home Services, and Home Nursing Agencies in Illinois. It contains detailed instructions for completing the application and the required fees. Filling out this application is mandatory for obtaining a license.
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How do I fill this out?
Before filling out the application, review the Home Health, Home Services, and Home Nursing Agency licensing rules and regulations. Collect all necessary information and documents. Use Adobe to type the application or fill it out manually if preferred.
How to fill out the Home Health and Nursing Agency Initial Licensure Application?
1
Review the relevant rules and regulations.
2
Collect necessary information and documents.
3
Complete all mandatory sections of the application.
4
Enclose the required licensing fee.
5
Submit the application to the Illinois Department of Public Health.
Who needs the Home Health and Nursing Agency Initial Licensure Application?
1
Individuals seeking to establish a Home Health Agency need this application to obtain licensure.
2
Businesses aiming to provide Home Services must complete this form for legal operation.
3
Agencies offering Home Nursing Services require licensure through this application.
4
Entities planning to provide Home Nursing Placement services need to submit this form.
5
Service providers wanting to establish Home Services Placement agencies must fill out this application.
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What are the instructions for submitting this form?
Submit the completed application form along with the required attachments and licensing fee to the following address: Illinois Department of Public Health, Health Care Facilities and Programs, 4th Floor, 525 West Jefferson Street, Springfield, IL 62761-0001. Ensure all documents are complete and accurate before sending. Retain a copy of the application for your records.
What are the important dates for this form in 2024 and 2025?
Ensure to check the Illinois Department of Public Health's website for any updates on submission deadlines for 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to ensure that all Home Health, Home Services, and Home Nursing Agencies in Illinois comply with state regulations. Proper submission of this application is mandatory for obtaining licensure. It aids in maintaining high standards of services within the state.
Tell me about this form and its components and fields line-by-line.
- 1. Agency Name and Physical Address: Input the official name and physical address of the agency.
- 2. Agency Phone Number: Provide the contact phone number for the agency.
- 3. Business Hours: Specify the operating hours for the agency.
- 4. Mailing Address: If different from the physical address, provide the mailing address.
- 5. Illinois County of Agency Headquarters: Indicate the county where the agency's headquarters is located.
- 6. Fiscal Period: Specify the fiscal period start and end dates for the agency.
- 7. Affidavit of Agreement: Read through and sign as the agency administrator or manager, confirming the accuracy of the information.
- 8. Contact Person: Provide details for a contact person different from the agency phone number.
What happens if I fail to submit this form?
Failure to submit this form can lead to the inability to legally operate the agency.
- Legal Consequences: Operating without licensure may result in legal action.
- Financial Penalties: Failure to comply can lead to fines and penalties.
- Operational Disruptions: The agency will not be allowed to function until licensure is obtained.
How do I know when to use this form?
- 1. Starting a New Agency: When creating a new Home Health, Home Service, or Home Nursing Agency.
- 2. Renewing Licensure: If required for the renewal process within the agency's operational timeline.
Frequently Asked Questions
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Are there any fees required with this application?
Yes, the required licensing fees are specified within the application instructions.
Do I need to keep a copy of the application after submission?
Yes, it is advised to retain a copy for future reference.
What are the steps to complete the application?
Review the rules, collect documents, fill out the form, enclose the fee, and submit to the Illinois Department of Public Health.
How do I ensure my application is accurate?
Double-check all information and ensure compliance with the instructions before submitting.
Can I use a handwritten signature on PrintFriendly?
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