Form 445103 at a glance
What it is: Form Number 445103 is the Home Health Agency Initial Licensure Application of the State of Illinois Illinois Department of Public Health.
Who signs: Sign as the Agency Administrator / Agency Manager on the Signature - Agency Administrator / Agency Manager (ORIGINAL ONLY) line and fill in the Date Signed. On Attachment B - Agency Supervisor Qualification Review Form Page 3, the agency supervisor signs the Signature of Applicant (Original Only) line and fills in the Date. On Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form, the Medical Social Worker signs the Signature of Medical Social Worker Applicant (Original Only) line and fills in the Date. On Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form, a Social Worker Assistant, if there is one, signs the Signature of Social Worker Assistant (if applicable) (Original Only) line.
What to bring and attach to Form 445103
Enclose the completed application and appropriate attachments, accompanied by the required licensing fee.
Retain a copy of the application for future reference.
The application shall be accompanied by a certificate of insurance documenting minimum liability coverage of $1 million per occurrence and $3 million in the aggregate. (checked November 8, 2026)
Provide copies of policies and procedures for: Complaint resolution as required per Section 245.30(b)(3). Employee health and safety as required per section 245.30 I(1)(H) and(I). Infection control as required per Section 245.75. Health care worker background check compliance per section 245.72 and mandated reporting compliance per Section 245.250. Supervisory visits of various disciplines as per 245.40. Client records management, retention, and release requirements per Section 245.200(b). Employee training as required in Section 245.70, 245.71 and 245.211. Criteria for acceptance of patients and clients as required per Section 245.200(d). Documents demonstrating the agency is registered with the IDPH Web Portal and granted access to the Health Care Worker Registry.
A filled-in Form 445103 example: a new agency fills out General Information
How to fill out Form 445103, box by box
GENERAL INFORMATION Agency Name and Physical Address
Under GENERAL INFORMATION Agency Name and Physical Address, fill in the Agency Name, Agency Phone Number, DBA and Agency Fax Number.
Fill in the Address, City, State, ZIP Code and Email Address, and the Illinois county of agency Headquarters.
Mailing Address
If the agency's mailing address is different from the physical address listed under GENERAL INFORMATION Agency Name and Physical Address, fill in the Mailing Address, City, State and ZIP Code.
Business Hours, days of operation and Fiscal Period
Fill in the Business Hours a.m. to p.m. and the Days of operation.
Enter the Fiscal Period (i.e., MONTH/DAY) to (MONTH/DAY).
AFFIDAVIT OF AGREEMENT
Under AFFIDAVIT OF AGREEMENT: The date 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.
Fill in the Print Name of Agency Administrator / Agency Manager and the Administrator's / Agency Manager's Title.
Fill in the Contact Person - Name and Phone Number: Contact Person Must be Different from Agency Phone Number.
OWNERSHIP
Select one TYPE OF ORGANIZATION from the drop-down menu that corresponds to the type of agency registered with the Secretary of State or county registrar (CHOOSE ONE TYPE): GOVERNMENTAL, NON-PROFIT or PROPRIETARY.
AGENCY INFORMATION
Under AGENCY INFORMATION, enter the Legal Entity Name: List the name of corporation or LLC as registered with the Secretary of State or county - Do not list shareholder names.
ILLINOIS REGISTERED AGENT
Under ILLINOIS REGISTERED AGENT, enter the Name of Illinois Registered Agent as listed in the Secretary of State Corporation File Detail Report; the Illinois Registered agent's address must be in Illinois.
STOCKHOLDER INFORMATION
Under STOCKHOLDER INFORMATION (Corporations only), list the number of shares held and the percentage of total shares held by shareholders with more than 5% of common stock.
GOVERNING BODY
GOVERNING BODY - Complete only for agencies registered with the Secretary of State as a corporation.
President and secretary positions are required.
Have any of the following been convicted of a felony or of two or more misdemeanors involving moral turpitude in the last FIVE years? (If yes, attach explanation as Exhibit A)
Does the administrator/agency manager have responsibility for more than one Illinois agency? If yes, list additional license numbers and agency names.
HOME HEALTH AGENCY CONTRACTS
Indicate which services your agency intends to offer.
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.
SKILLED NURSING may not be contracted unless it is to cover vacations of regular staff or for specialized skills not routinely offered.
If you use contracted SKILLED NURSING, provide the rationale.
The agency must have an RN listed (can be part time) as a separate employee from the supervisor.
Provide a copy of the job description for each service the agency intends to offer as required per Section 245.30(c).
AGENCY CONTRACTS (add additional copies of this form if necessary) Provide a signed copy of the affiliation agreement with other health care providers.
A HHA must have as their primary service skilled nursing.
Geographic Service Area
Identify the counties or portions of counties where the home health 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. Do not include radius miles as a description of the service area.
It is recommended for initial licenses to start with 3-5 counties.
LICENSED OR REGISTERED EMPLOYEES
List ALL licensed, certified, and contractual employees. Submit copies of licenses for professional staff (Staff Nurses, PT/OT/ST, etc.)
List at least ONE contracted employee for each applicable specialty (PT, OT, SP, or MSW).
Copy and attach additional pages as needed.
F/T=Full Time, P/T=Part Time and Contract=Contractual Employees.
Sources of Revenue
Check the types of revenue sources of income of the agency.
Description of Services
Agencies provide a description of the services to be provided (245.90a)3) C).
If your situation is different
The organization is a sole proprietorship
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.
"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.
"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."
Making a false statement may subject the licensee to contempt of court.
Attachment A - Administrator Qualification Review Form
YOUR CURRENT EMPLOYER MUST BE THE AGENCY IDENTIFIED IN THIS APPLICATION.
Describe your relevant work experience for the last five years.
Resumes are not accepted in lieu of completion of this portion of the form.
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.
Attachment B - Agency Supervisor Qualification Review Form
Section 245.30 requires that the agency supervisor must be a registered nurse.
ATTACH A COPY OF YOUR CURRENT ILLINOIS LICENSE.
Common questions about Form 445103
Where do I file it?
License fee made payable to the Illinois Department of Public Health (check or money order), sent to: Illinois Department of Public Health Health Care Facilities and Programs, 4th Floor, 525 W. Jefferson St. Springfield, IL 62761-0001.
Are there fees?
The license fee is $1,500 for a single home health agency license every two years. (checked November 8, 2026)
Sources
[1] Form 445103 (Updated 11/2024), Home Health Agency Initial Licensure Application, Illinois Department of Public Health (the Official source link on this page).
