Get Illinois Department Of Halth Form 445108

Navigating the Illinois Department of Health Form 445108 can be straightforward when you know what to do. This guide provides detailed instructions to help users fill out the Ambulatory Surgical Treatment Center Renewal Licensure form with confidence and clarity.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the facility name and address details. Make sure to include the full street address, city, state, zip code, and county. Provide a valid phone number and fax number, as well as an email address to ensure communication is established.
3. Indicate the administrator's name at the bottom of the form. The facility's administrator must review the application for accuracy before signing and dating the form in the designated spaces.
4. Choose the type of ownership by marking an 'X' in the appropriate box. The options include sole proprietorship, partnership, corporation, and others.
5. If applicable, fill in the details for the registered agent, including their name, address, and contact number. This is necessary for certain types of ownership.
6. Provide ownership information, including the name of the parent firm or organization and the state wherein it is incorporated. List the names and addresses of the facility's officers as required.
7. Answer the questions regarding any history of conviction for felonies or misdemeanors by checking yes or no, as needed. If necessary, attach an explanation.
8. Outline the medical staff by listing their specialties and license numbers. This section may require additional documentation, such as resumes, which should be attached.
9. Make sure to complete the application addendum if you are a sole proprietor, confirming compliance with child support orders.
10. Finally, review the entire form for completeness and accuracy. Once all sections are filled out, save your changes. You can then download, print, or share the completed form as needed.

Complete and submit your Illinois Department of Health Form 445108 online to ensure compliance and secure your licensure.