Get Application For License To Operate Hospice - Illinois Department Of ... - Idph State Il

Filling out the Application for License to Operate Hospice is an essential step in establishing a hospice program in Illinois. This guide provides clear instructions on how to complete the application online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the application effectively.

1. Press the ‘Get Form’ button to access the application and open it in your online editor.
2. Begin by entering your agency name and mailing address, including city, state, and zip code. If your facility's physical location differs, provide that information in the designated section.
3. Indicate your agency's phone number, fax number, and email address. Specify the days of the week and business hours during which the agency operates.
4. Identify the contact person for the hospice and provide their phone number.
5. Select the type of hospice services offered. Check all applicable services such as nursing, social services, or bereavement counseling.
6. If your hospice maintains multiple locations, indicate yes or no and list the addresses and phone numbers of any additional locations as necessary.
7. Fill out the type of hospice affiliation and control section. Specify whether your hospice is operated as a government agency, profit, or nonprofit entity.
8. Complete the professional staffing list by providing licenses or registration numbers, and indicate if personnel are full-time or part-time.
9. Outline your service categories and detail which services you provide, and whether they are direct or contracted.
10. Provide a comprehensive list of your sources of income for the fiscal year, ensuring that the percentages total 100%.
11. If renewing your application, detail the hospice census report for the fiscal year, including new admissions, average patient counts, and patient terminations.
12. Attach any required documents including the annual hospice service plan, financial audit for the current fiscal year, and the hospice’s current annual budget.
13. Enter the authorized signatures of the applicant and individual verifying the signature, along with their titles and the date.
14. Once all sections are completed, save your changes. You can then download, print, or share the form as needed.

Complete your hospice license application online today to ensure compliance with the Illinois Department of Public Health.