445103 Form PDF Details

The 445103 form is the official Initial Licensure Application required by the Illinois Department of Public Health. Any entity wishing to operate a home health, home services, or home nursing agency in Illinois must complete and submit this form. The IDPH recommends reviewing the current licensing rules and regulations online before starting the application.

The form asks for basic agency details such as name, address, and ownership type. It also requires governance information, including stockholder data for corporations and registered agent details where applicable. Application fees range from $25 for a single home health license to $1,500 for home nursing or home services agency licenses, all payable to the Illinois Department of Public Health.

Agencies managing ongoing compliance may also need a home health audit form to track regulatory requirements. Facilities that operate residential care settings should review the nursing home form for additional licensing steps. Illinois providers can also reference the HFS 3654 form for related Department of Public Aid requirements.

QuestionAnswer
Form Name445103 Form
Form Length25 pages
Fillable?No
Fillable fields0
Avg. time to fill out6 min 15 sec
Other namesillinois temporary nursing home administrator license form, illinois home services application, illinois home nursing application, illinois dph agency

Form Preview Example

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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.idph.state.il.us under "A" Administrative Rules, "Administrative Rules Only." 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.

Form Number (445103)

Page 1 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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.

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.

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 Services Agency (complete pages 2, 3, 4, 5, 7, 8, 10, 12, 23, 24, 25)

Home Nursing Agency (complete pages 2, 3, 4, 5, 7, 8, 10, 12, 23, 24, 25)

Home Nursing Placement Agency (complete pages 2, 3, 4, 5, 7, 8, 11, 12, 23, 24, 25)

Home Services Placement Agency (complete pages 2, 3, 4, 5, 7, 8, 11, 12, 23, 24, 25)

FOR OFFICE USE ONLY

License Number

License Number

License Number

Form Number (445103)

Page 2 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

GENERAL INFORMATION

Agency Name and Address

Agency Name

 

 

 

Agency Phone Number

 

 

 

 

 

 

 

 

 

 

 

Agency Fax Number

 

 

 

 

 

Address

 

 

 

 

Business Hours

 

a.m. to

 

p.m.

 

 

 

 

 

City

 

 

 

 

Days of the Week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility Address (If agency's physical location is different from the mailing address above)

Address

City

 

 

 

State

 

ZIP Code

 

Illinois County of Agency Headquarters

 

 

 

 

 

 

(Select from drop down box)

Fiscal Period (i.e MONTH/DAY)

 

 

to

(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.

Signature-Agency Administrator/Agency Manager (ORIGINAL ONLY)

Date Signed

 

 

 

 

 

Name of Agency Administrator/Agency Manager

Administrator's /Agency Manager's Title

Contact Person

Contact Person - Name

Phone Number

Form Number (445103)

Page 3 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

OWNERSHIP

Select one TYPE OF ORGANIZATION from the drop down list that corresponds to your agency

(CHOOSE ONE TYPE)

GOVERNMENTAL

 

NON-PROFIT

 

PROPRIETARY

 

 

*RA - Registered agent required, see below.

 

(Add appropriate response from drop down box)

**Note: If organization is a sole proprietorship, the declaration on Page 8 must be completed.

AGENCY INFORMATION

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

 

 

 

 

 

 

Phone Number of Registered Agent

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.

 

NAME OF STOCKHOLDER

 

 

SHARES HELD

 

 

PERCENTAGE OF SHARES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If a corporation or LLC, name of corporation or company

State of incorporation of the company

Form Number (445103)

Page 4 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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).

OfficeNameAddressState ZIP Code

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.

Yes No

License Number

 

Agency Name

License Number

 

Agency Name

Does the home health agency supervisor have responsibility for more than one Illinois agency?

Yes No

License Number

 

Agency Name

License Number

 

Agency Name

Form Number (445103)

Page 5 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME HEALTH ONLY

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

 

 

 

H-Skilled Nursing

I-Physical Therapy

 

 

 

 

J-Speech Therapy

K-Occupational Therapy

 

 

 

 

L-Med. Social Worker

M-Home Health Aide

 

 

Type of Service

 

 

 

 

 

 

H-Skilled Nursing

I-Physical Therapy

 

 

 

 

J-Speech Therapy

K-Occupational Therapy

 

 

 

 

L-Med. Social Worker

M-Home Health Aide

 

 

 

 

Type of Service

 

 

 

H-Skilled Nursing

I-Physical Therapy

 

 

 

 

J-Speech Therapy

K-Occupational Therapy

 

 

 

 

L-Med. Social Worker

M-Home Health Aide

 

 

Type of Service

 

 

 

 

 

 

H-Skilled Nursing

I-Physical Therapy

 

 

 

 

J-Speech Therapy

K-Occupational Therapy

 

 

 

 

L-Med. Social Worker

M-Home Health Aide

 

 

 

 

Type of Service

 

 

 

H-Skilled Nursing

I-Physical Therapy

 

 

 

 

J-Speech Therapy

K-Occupational Therapy

 

 

 

 

L-Med. Social Worker

M-Home Health Aide

 

 

Form Number (445103)

Page 6 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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.

County

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form Number (445103)

Page 7 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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

Form Number (445103)

Page 8 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME HEALTH AGENCY ONLY

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

Expiration Date

F/T

P/T

Administrator Name

Agency Supervisor Name

Job Title/Name

License Number

 

Expiration Date

Contract

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please copy and attach additional pages as needed.

Form Number (445103)

Page 9 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME SERVICES/HOME NURSING ONLY

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.

Job Title

License Number

 

Expiration Date

F/T

P/T

 

 

 

 

 

 

 

 

Agency Manager Name

 

 

 

 

 

Contract

Form Number (445103)

Page 10 of 25

How to Edit 445103 Form Online for Free

Steps to Complete the 445103 Form Online

FormsPal's PDF editor is designed to make completing government forms straightforward. Follow these steps to fill out the 445103 Illinois home health licensure form:

Step 1: Click the orange "Get Form Here" button on this page.

Step 2: The file edit page will open. You can add, change, highlight, check, cross, or erase fields and text.

Get the illinois initial PDF and provide the details for every area:

illinois form 445103 empty spaces to fill out

In the License Number, Form Number, and Page of area, type in your data.

illinois form 445103 License Number, Form Number, and Page of fields to insert

Complete the Agency Name and Address section, including Agency Name, Address, City, State, ZIP Code, Days of the Week, Email Address, Agency Phone Number, Agency Fax Number, Business Hours, and Facility Address.

Filling in illinois form 445103 step 3

Specify the rights and obligations in the Signature, Date Signed, Name of Agency Administrator, Administrators Agency Managers, Contact Person Name, and Phone Number fields.

step 4 to entering details in illinois form 445103

Complete the Type of Organization section by selecting GOVERNMENTAL, NONPROFIT, or PROPRIETARY. Fill in the Agency Information fields: Legal Owner Name, Street Address, City, Phone Number, State, ZIP Code, and Illinois Registered Agent details.

step 5 to completing illinois form 445103

Step 3: Click Done to save the file, then download it to your device.

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