Get Home Health, Home Services, Home Nursing Agency Renewal/change Of Ownership Licensure Application

The Home Health, Home Services, Home Nursing Agency Renewal/Change of Ownership Licensure Application is an essential document for maintaining compliance with state regulations. This guide provides clear, step-by-step instructions to assist users in completing the application online.

Follow the steps to accurately complete your application.

1. Click the 'Get Form' button to obtain the application form and open it in the relevant application editor.
2. Review the type of agency you are applying for. Indicate whether your agency is a home health agency, home services agency, home nursing agency, home nursing placement agency, or home services placement agency by checking the appropriate boxes as required.
3. Fill in the general information section, including the agency name, address, phone number, fax number, email address, and business hours. If your agency has a physical location that differs from the mailing address, provide that information as well.
4. Complete the ownership details by providing the legal owner's name and address, as well as the name and address of the Illinois registered agent if applicable.
5. Input stockholder information if your organization is a corporation. List shareholders with more than 5 percent of common stock along with shares held and percentages.
6. Detail the governing body by identifying the officers of your agency along with their contact information. Also, indicate whether the administrator has responsibility for multiple Illinois agencies.
7. Report the total number of full-time equivalent (FTE) employees in various job classifications for home health, home services, and home nursing services as applicable.
8. For home health agencies, provide information regarding agency contracts and the geographic service area your agency intends to serve.
9. Complete the sections for revenue sources, total number of patients served, admissions, and discharges during the fiscal period.
10. Fill in the affidavits and declarations as required, including the Sole Proprietor Declaration if applicable.
11. Ensure all necessary attachments, including licenses and qualification forms for administrators, supervisors, and other key personnel, are included before submitting your application.
12. Review all information for accuracy, save your changes, and proceed to download or print your completed form as needed.

Ensure your agency complies with the latest regulations by completing your application online today.