Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the application for the designated caregiver registry identification card online and open it in your browser.
2. Select the appropriate application type by checking one of the boxes indicating whether this is a new application or a new application for a current patient. Ensure you understand the implications of each choice before proceeding.
3. Fill in the caregiver information section. Enter your social security number, driver’s license number, and state. Add your first name, middle name, last name, home address, apartment or suite number (if applicable), city, county, state, ZIP code, telephone number, email address, and date of birth. Select your gender by clicking the appropriate box.
4. Complete the qualifying patient information section by providing the patient's first name, middle name, last name, and home address details in the same manner as you did for your caregiver information.
5. Have the qualifying patient sign and date the application in the designated area, confirming their intention and understanding of the application.
6. Review the attestation section carefully. Read through the required certifications and ensure that the information you provided is accurate. Sign and date this section accordingly.
7. Choose the correct application fee that corresponds with your application type. Record the amount on the application and prepare the payment by check or money order payable to the Illinois Department of Public Health.
8. Gather the required documents as detailed in the application. This includes the non-refundable application fee, a current photograph, proof of age and identity, and proof of residency. Ensure all documents meet the specified requirements.
9. Once completed, save any changes made to your application. You can then choose to download, print, or share the form for submission.

Complete your application online today to become a designated caregiver.