Get Hha Administrator Qualification Review Form - Idph State Il

Filling out the HHA Administrator Qualification Review Form is an essential step for individuals seeking to establish their qualifications as administrators for home health agencies in Illinois. This guide provides comprehensive instructions on navigating the online form effectively.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to retrieve the form and open it for completion.
2. Fill in the home health agency information, including the agency's name, address, city, state, and ZIP code. Ensure accuracy to avoid any processing delays.
3. Enter the administrator's personal details: last name, first name, middle initial, address, city, state, daytime phone number, ZIP code, and extension if applicable.
4. Select one of the categories provided that best fits your qualifications as an administrator. Options include physician, registered nurse, or individuals with relevant experience.
5. Indicate the highest educational level you have obtained by checking the appropriate box. Include details of the colleges attended, along with their addresses, dates of graduation, specialties, and degrees obtained.
6. List any professional licenses, registrations, or certifications currently held. Include the license number, expiration date, and the state that issued each credential.
7. Provide a detailed work experience summary for the past five years. List current employment first and detail the positions held, including starting and ending dates, hours worked weekly, and duties performed.
8. Answer the questions regarding criminal offenses and licensure issues truthfully. If applicable, attach a detailed explanation on a separate sheet.
9. Affirm the accuracy of your information by signing the application in the designated area followed by the date of signing.
10. After completing the form, you can save the changes, download, print, or share the form as needed.

Complete your application online to ensure a smooth qualification review process.