Illinois Home Nursing Application Details

445103 Form - what is it and how do you fill it out? This form is for taxpayers to use in order to claim a Mississippi income tax credit. The amount of the credit is based on the taxpayer's adjusted gross income, filing status, and number of qualifying children. Let's take a closer look at how to complete this form. In order to qualify for the Mississippi income tax credit, taxpayers must meet certain requirements. First, their adjusted gross income must be less than $50,000. Second, they must file as either single or head of household. Third, they must have one or more qualifying children. And finally, their total credits cannot exceed $500 per year.

In the table, there's some good information in regards to the 445103 form. There, you'll discover the specifics of the PDF you intend to fill in, such as the estimated time required to complete it and also other details.

QuestionAnswer
Form Name445103 Form
Form Length25 pages
Fillable?Yes
Fillable fields681
Avg. time to fill out35 min 37 sec
Other names445103, illinois form 445103, illinois initial, agency health application

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

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME NURSING/HOME SERVICES PLACEMENT ONLY

List ALL licensed, certified registry persons. FOR HOMEMAKER OR CERTIFIED NURSE AIDE, LIST INITIALS OF REGISTRY PERSON.

Job Title

License Number

Expiration Date

 

 

 

 

 

 

Agency Manager Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form Number (445103)

Page 11 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

Please check the types of revenue sources of income of the agency:

Sources of Revenue

Local Funds

Local Health Department

Government Funds

Medicare Parts A & B (Home Health Only)

Medicaid

Other Government Funds

Other Funds

Self-Pay

HMO/PPO

Commercial Insurance

Other Revenue

ATTACHMENTS REQUIRED

Attach a copy of the Charges for Services (Fee Schedule) by types of services provided by the agency (ALL Agencies) 245.90a)3)G)

Home health agencies ONLY, attach a copy of any affiliation agreements with other health care providers. 245.90a)3)H)

All agencies EXCEPT home health agencies shall attach a sample copy of the Client Service Contracts as per Section 245.210b), 245.220 and 245.225.

Placement agencies shall attach a sample copy of the worker contract as per

Section 245.214 e) and 245.212.e).

All Agencies provide a description of the services to be provided for each license type you are applying for: 245.90a)3)C)

HOME SERVICES AGENCIES ONLY shall attach a copy of the list of types of services offered by the agency and the scope of the work to be provided under each area. 245.210(a)

Form Number (445103)

Page 12 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME HEALTH AGENCY ONLY

Attachment A - Administrator Qualification Review Form

Home Health Agency Name

Address

City

 

 

 

State

 

ZIP Code

 

Administrator Information

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

First Name

 

 

 

 

 

Middle Initial

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

ZIP Code

 

Daytime Phone Number

 

 

 

 

 

 

 

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check one of the following categories. Section 245.20 "Home Health Agency Administrator" requires that the administrator must be one of the following:

Physician Registered Nurse

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

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

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

ZIP Code

 

Date of Graduation

 

 

Specialty/Degree

 

 

 

 

Name of College

 

 

 

 

 

 

 

 

Address of College

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

ZIP Code

 

Date of Graduation

 

Specialty/Degree

 

 

 

 

Please list the high school attended, the address, and date of graduation.

Name of High School

 

 

Date of Graduation

 

 

Address of High School

 

 

 

 

 

 

 

 

City

State

 

ZIP Code

Form Number (445103)

 

 

 

 

 

 

Page 13 of 25

 

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

Ending (month and year)

 

Total Hours Worked Weekly

 

 

 

 

 

 

 

 

 

 

 

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Previous Employer Name

 

 

 

 

 

 

 

 

 

Address of Previous Employer

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

 

 

Ending (month and year)

 

Total Hours Worked Weekly

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attachment A - Administrator Qualification Review Form Page 2

Form Number (445103)

Page 14 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

Previous Employer Name

 

 

 

 

 

 

 

 

 

Address of Previous Employer

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

 

ZIP Code

 

Starting (month and year)

 

Ending (month and year)

 

 

Total Hours Worked Weekly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

Signature of Applicant (Original Only)

Date Signed

Attachment A -Administrator Qualification Review Form Page 3

 

Form Number (445103)

Page 15 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME HEALTH AGENCY ONLY

Attachment B - Agency Supervisor Qualification Review Form

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.

Home Health Agency Name

Address

City

 

 

 

State

 

ZIP Code

 

Agency Supervisor Information

 

 

 

 

 

 

 

 

 

 

Last Name

 

First Name

 

 

 

 

 

Middle Initial

 

Address

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

ZIP Code

 

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

City

 

 

State

 

 

ZIP Code

 

 

Date of Graduation

 

Specialty/Degree

 

 

 

 

 

 

 

Name of College

 

 

 

 

 

 

 

 

 

 

 

Address of College

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

ZIP Code

 

 

Date of Graduation

 

Specialty/Degree

 

 

 

 

 

 

 

Please list the high school attended, the address, and date of graduation.

 

 

 

 

 

 

Name of High School

 

 

 

 

Date of Graduation

 

 

Address of High School

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

 

ZIP Code

Form Number (445103)

 

 

 

 

 

 

 

 

 

Page 16 of 25

 

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

 

Ending (month and year)

 

Total Hours Worked Weekly

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Previous Employer Name

 

 

 

 

 

 

 

 

Address of Previous Employer

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

Ending (month and year)

 

Total Hours Worked Weekly

 

 

 

 

 

 

 

 

 

 

 

 

 

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Atttachment B-Agency Supervisor Qualification Review Form

Page 2

Form Number (445103)

Page 17 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

Previous Employer Name

 

 

 

 

 

 

 

 

 

Address of Previous Employer

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

 

Ending (month and year)

 

Total Hours Worked Weekly

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.

Signature of Applicant (Original Only)

Date

Attachment B - Agency Supervisor Qualification Review Form Page 3

 

Form Number (445103)

Page 18 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME HEALTH ONLY - If Applicable

Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form

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.

HHA Agency Name

Address

City

 

 

 

State

 

ZIP Code

 

Applicant Name

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

First Name

 

 

 

 

 

 

Middle Initial

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

ZIP Code

 

Daytime Phone Number

 

 

 

 

 

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form Number (445103)

Page 19 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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.

List applicable professional licenses, registrations and/or certifications currently held. Attach a copy of your

current Illinois license.

Date MSW Degree Awarded (if applicable)

 

Date of Initial License

Expiration Date of Current License

 

 

State of Issuance

Name of College

 

 

Date of Graduation

Address of College

 

 

 

 

 

 

City

 

 

State

 

ZIP Code

Specialty Degree

 

 

 

 

 

 

Describe your relevant work experience to meet the requirements of Section 245.20.

Employer Name

Address of Employer

City

 

 

 

 

State

 

ZIP Code

 

 

Starting (month and year)

 

Ending (month and year)

 

Total Hours Worked Weekly

 

Duties

 

 

 

 

 

 

 

 

 

 

Employer Name

Address of Employer

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

Ending (month and year)

 

Total Hours Worked Weekly

Duties

 

 

 

 

 

 

 

 

 

IF YOU ARE A MEDICAL SOCIAL WORKER, PROCEED TO THE SIGNATURE BLOCK AND SIGN AT THE BOTTOM OF PAGE FOUR.

Attachment D - Medical Social Worker/Social Work Assistant Work Qualification Review Form Page 2

 

Form Number (445103)

Page 20 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

HOME HEALTH ONLY

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.

Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.

Name of College

 

 

 

 

 

 

 

Address of College

 

 

 

 

 

 

 

City

 

 

 

State

 

ZIP Code

 

Date of Graduation

 

 

Specialty/Degree

 

 

 

 

Describe your relevant work experience to meet the requirements of Section 245.20.

Employer Name

Address of Employer

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

Ending (month and year)

 

Total Hours Worked Weekly

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

Address of Employer

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

Ending (month and year)

 

Total Hours Worked Weekly

Duties

 

 

 

 

 

 

 

 

 

Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form Page 3

 

Form Number (445103)

Page 21 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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)

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 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

Form Number (445103)

Page 22 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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.

Home Nursing 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 245.30 for the requirements for the agency manager.

Form Number (445103)

Page 23 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

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.

Describe your relevant work experience for the last five years.

(1)List the agency this application applies to as CURRENT employer, and work backwards. For INITIAL application, start date can be "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 agency manager of a home services/home nursing agency, home services placement agency, home nursing placement 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

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

 

Ending (month and year)

 

 

Total Hours Worked Weekly

 

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Previous Employer Name

 

 

 

 

 

 

 

 

 

 

Previous Employer Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

ZIP Code

 

Starting (month and year)

 

 

 

Ending (month and year)

 

 

Total Hours Worked Weekly

 

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attachment E - Agency Manager Review Form Page 2

 

Form Number (445103)

Page 24 of 25

State of Illinois

Illinois Department of Public Health

Home Health, Home Services, Home Nursing Agency Initial Licensure

Application

Previous Employer Name

Previous Employer Address

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

ZIP Code

 

Starting (month and year)

 

 

Ending (month and year)

 

 

Total Hours Worked Weekly

 

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 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

Date

(Original Signature)

 

ATTACH A COPY OF YOUR CURRENT ILLINOIS LICENSE, IF APPLICABLE

Attachment E - Agency Manager Qualification Review Form Page 3

Form Number (445103)

Page 25 of 25

How to Edit 445103 Form

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The Select one TYPE OF ORGANIZATION, GOVERNMENTAL, NON-PROFIT, PROPRIETARY, *RA - Registered agent required, (Add appropriate response from, **Note: If organization is a sole, AGENCY INFORMATION, Name of Legal Owner, Street Address, City, Phone Number, State, ZIP Code, and The Illinois Registered agent's section will be applied to record the rights or obligations of both sides.

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