Home Health, Services, Nursing Agency Renewal/change Of Ownership Licensure Application 445104 COOS HHA Services & Placement Renewal

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State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application

The completed application and appropriate attachments, accompanied by the required license fee
made payable to the Illinois Department of Public Health (check or money order), should be sent
to:
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
HEALTH CARE FACILITIES AND PROGRAMS SECTION
525 W. JEFFERSON ST., FOURTH FLOOR
SPRINGFIELD, IL 62761-0001
Please enclose the completed application and appropriate attachments, accompanied by the
required licensing fee:
$ 25 license fee for single home health license
$1,500 license fee for home nursing agency
$1,500 license fee for home services agency
$ 500 license fee for home nursing placement agency
$ 500 license fee for home services placement agency

DUE DATE IS 60 DAYS PRIOR TO THE EXPIRATION OF THE
CURRENT LICENSE

NOTE: Please retain a copy of the application for future reference.
IF YOU DO NOT TYPE THE APPLICATION USING ADOBE AND CHOOSE TO COMPLETE THE APPLICATION IN
WRITING, BE SURE TO MAKE NOTE OF DROP-DOWN BOXES TO PROPERLY COMPLETE THE APPLICATION.

Form Number (445104) (revised 2-2014)

Page 1 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application

THIS PAGE IS PART OF THE APPLICATION AND MUST BE FILLED OUT WHERE NECESSARY.
PLEASE CHECK ALL APPLICABLE AGENCY TYPES FOR WHICH YOU ARE SUBMITTING AN
APPLICATION.
IMPORTANT NOTICE: Pursuant to the Home Health Agency Licensing Act (210 ILCS 55/1 et seq.) and the rules and
regulations of the Illinois Department of Public Health, titled "Home Health, Home Services and Home Nursing Agency
Code" (77 Ill. Adm. Code 245), this state agency is requesting disclosure of information that is necessary to accomplish the
statutory purpose as outlined under the act and the attendant rules. Disclosure of this information is mandatory. This
form has been approved by the Forms Management Center.

CHECK THE TYPE OF AGENCY THIS APPLICATION IS BEING COMPLETED FOR. COMPLETE ONLY THE PAGES
LISTED NEXT TO THE AGENCY TYPE. FAILURE TO COMPLETE ONLY THE REQUIRED PAGES COULD RESULT
IN A DELAY IN PROCESSING THE APPLICATION AND ISSUANCE OF THE LICENSE.

Home Health Agency (complete pages 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25)
Home Services Agency (complete pages 2, 3, 4, 5, 6, 8, 9, 11, 13, 15, 26, 27, 28)
Home Nursing Agency (complete pages 2, 3, 4, 5, 6, 8, 9, 11, 13, 15, 26, 27, 28)
Home Nursing Placement Agency (complete pages 2, 3, 4, 5, 6, 8, 9, 11, 14, 15, 26, 27, 28)
Home Services Placement Agency (complete pages 2, 3, 4, 5, 6, 8, 9,11, 14, 15, 26, 27, 28)

FOR OFFICE USE ONLY

License Number
License Number
License Number

Form Number (445104) (revised 2-2014)

Page 2 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Renewal

License Expiration Date

License Number

Change of Ownership

Medicare Number

License Number
License Number

IMPORTANT NOTICE - Pursuant to the Home Health Agency Licensing Act (210 ILCS 55/1 et seq.) and the rules and
regulations of the Illinois Department of Public Health, titled "Home Health, Home Service and Home Nursing Agency
Code" (77 Ill. Adm. Code 245), this state agency is requesting disclosure of information that is necessary to accomplish the
statutory purpose as outlined under the act and the attendant rules. Disclosure of this information is mandatory. This form
has been approved by the Forms Management Center.

GENERAL INFORMATION
Agency Name and Address
Agency Name

Agency Phone
Agency Fax

Address

Business Hours

City

Days of the Week

State

ZIP Code

a.m. to

p.m.

E-mail Address

Facility Address (If agency's physical location is different from the mailing address above.)
Address
City

State

ZIP Code

Illinois County of Agency
Fiscal Period (i.e. Month/Day)

to

Month/Day

AFFIDAVIT OF AGREEMENT
The data contained in this application has been reviewed by me and is accurate to the best of my
knowledge. I will comply with all rules and regulations governing the licensing of this agency.
Signature Agency Administrator/Agency Manager (ORIGINAL ONLY)

Date Signed

Name of Agency Administrator/Agency Manager

Administrator's Title

Contact Person

Name of Contact Person
Form Number (445104) (revised 2-2014)

Phone Number
Page 3 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
BRANCH OFFICE INFORMATION
No

Yes

Does your agency maintain branch offices?
If yes, list the location of each branch office.
Address/City

County

ZIP Code

*Is this a change in information from the previous year's application?

Phone Number

Yes

No

Yes

No

Date Branch
Location Approved*

OWNERSHIP
Did the type of organization change from previous year's application?

Select one TYPE OF ORGANIZATION from the drop down list that corresponds to the type of agency you have.

(CHOOSE ONE TYPE)
GOVERNMENTAL

NON-PROFIT

PROPRIETARY

*RA - Registered agency required, see below.
**Note: If organization is a sole proprietorship, the declaration on Page 13 must be completed.

AGENCY INFORMATION
Name of Legal Owner
Street Address
City

State

ZIP Code

Phone Number

Form Number (445104) (revised 2-2014)

Page 4 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
The Illinois registered agent's address must be in Illinois. If you are unable to identify the registered agent by name, or have
misplaced a copy of the agency's ownership papers as registered, contact the Secretary of State's Office to identify the
agency's registered agent of record. www.ilsos.gov/corporatellc/

ILLINOIS REGISTERED AGENT
Name of Illinois Registered Agent
Street Address
City

State

ZIP Code

Phone Number

STOCKHOLDER INFORMATION

If the organization is a corporation, list the number of shares held and the percentage of total shares held by shareholders
with more than 5 percent of common stock. For any change in stock holder from the previous renewal submit a copy of
the document to support this change.
Name of Shareholder

Shares Held

Percentages of Shares

If a corporation or LLC, name of corporation or company
State of incorporation of company

Form Number (445104) (revised 2-2014)

Page 5 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
GOVERNING BODY
Identify the officers of the governing body of your agency. The governing body has legal authority and responsibility for the
conduct of the agency (Section 245.30 of the Illinois Administrative Code 245).

Office

Name of Individual

President
Vice President
Secretary
Treasurer
Does the administrator/agency manager have responsibility for more than one Illinois agency?
Yes

No

Yes

No

If "Yes," list additional license numbers and agency names.
License Number

Agency Name

License Number

Agency Name

Does the Home Health agency supervisor have responsibility for more than one Illinois agency?

License Number

Agency Name

License Number

Agency Name

Form Number (445104) (revised 2-2014)

Page 6 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application

HOME HEALTH AGENCY ONLY
AGENCY CONTRACTS (add additional copies of this form if necessary)
Please note that SKILLED NURSING may not be contracted unless it is to cover vacations of regular staff or for specialized
skills not routinely offered. SKILLED NURSING must be directly provided by the agency plus ONE OTHER RECOGNIZED
SERVICE in order to qualify as a home health agency pursuant to ILLINOIS law. If you use contracted SKILLED NURSING,
please provide rationale.
Legal Name and Address of Organization
Type of Service
H-Skilled Nursing

I-Physical Therapy

J-Speech Therapy

K-Occupational Therapy

L-Med. Social Worker

M-Home Health Aide

Type of Service
H-Skilled Nursing

I-Physical Therapy

J-Speech Therapy

K-Occupational Therapy

L-Med. Social Worker

M-Home Health Aide

Type of Service
H-Skilled Nursing

I-Physical Therapy

J-Speech Therapy

K-Occupational Therapy

L-Med. Social Worker

M-Home Health Aide

Type of Service
H-Skilled Nursing

I-Physical Therapy

J-Speech Therapy

K-Occupational Therapy

L-Med. Social Worker

M-Home Health Aide

Type of Service

Form Number (445104) (revised 2-2014)

H-Skilled Nursing

I-Physical Therapy

J-Speech Therapy

K-Occupational Therapy

L-Med. Social Worker

M-Home Health Aide

Page 7 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
GEOGRAPHIC SERVICE AREA
Identify the counties or portions of counties where the home health, home service, home nursing agency, home services
placement agency, home nurse placement agency intends to serve patients and distinguish if the counties are different for
each license. If the agency is approved to serve only a portion of a county, please place an asterisk (*) in front of the
county. Include all approved counties even if no patients were served in a particular county in the last fiscal year if you wish
to retain the county in your service area. Please do not include radius miles as a description of the service area. All service
areas must be contiguous.
County
County

TOTAL NUMBER OF DUPLICATED PATIENTS SERVED OUTSIDE OF ILLINOIS:
See page 11 for definition of duplicated patients.

Form Number (445104) (revised 2-2014)

Page 8 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Please check the types of revenue sources of income of this agency.
Sources of Revenue
Local Funds
Local Health Department
Government Funds
Medicare Parts A & B (Home Health only)
Medicaid
Other Government Funds
Other Funds
Self-pay
HMO/PPO
Commercial Insurance
Other Revenue

Home Services/Home Nursing/Home Services Placement/Home Nursing Placement
Provide a copy of the current contract per 245.220 for Home Services/Home Nursing
Provide a copy of the current contract per 245.225 for Home Services Placement/Home Nursing Placement

Form Number (445104) (revised 2-2014)

Page 9 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME HEALTH AGENCY ONLY
Services Provided

Patients by Service
Record the total number of patients, including duplicated* patients, receiving care in Illinois, in each category of service
during the last fiscal period. A duplicated patient could simultaneously be receiving multiple services.
COLUMN ONE - Record the total number of patients who received each service in Illinois.
COLUMN TWO - Record the total number of visits for each service provided in Illinois.
*A duplicated patient is an individual receiving service from a home health agency who is subsequently discharged and
later readmitted during the same reporting fiscal period. Such a patient is to be considered a new admit. A patient should
be counted each time he/she is readmitted during the same reporting period.

Type of Service

Total Number of Patients
and Duplicated Patients by
Service

Total Number of
Visits

Skilled Nursing
Physical Therapy
Speech Therapy
Occupational Therapy
Medical Social Work
Home Health Aide
Other
TOTAL

Only patients receiving home health services

Form Number (445104) (revised 2-2014)

Page 10 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
THIS PAGE IS TO BE COMPLETED BY ALL AGENCIES
Record the total number of clients, including duplicated clients, for the admissions and discharges during the
fiscal (reporting) period. Do not include client services exclusively under the Community Care Program (CCP),
Department of Human Services or Veteran Affairs. If there are no clients in any section, please indicate with a zero.

Home Health

Home Services

Home Nursing Agency

# of admissions of most recent fiscal period
# of discharges of most recent fiscal period
# of admissions for patients 65 or older
at time of admission of most recent fiscal period
patient/client census on last day of most recent
fiscal period

*A duplicated patient or client is an individual receiving services from an agency who is subsequently discharged and
later readmitted during the same reporting fiscal period. Such an individual is to be considered a new admission. An
individual should be counted each time he/she is readmitted during the same reporting period.

Home Services Placement Agency

Home Nursing Placement Agency

# of clients placed in past fiscal period

*A duplicated placement is an individual receiving placement services during the reporting fiscal year. Such an
individual is to be counted as many times as he/she receives a placement service during the same reporting period.

SOLE PROPRIETOR DECLARATION
Pursuant to Section 16 of the Illinois Administrative Procedures Act, the licensee is required to complete the Sole Proprietor
Declaration page if the organization is set up as a sole proprietorship. Check NA if not applicable.
PLEASE CHECK ONLY ONE BOX
I certify under penalty of perjury that I am not more than 30 days delinquent in complying with a child support order.
Failure to do so may result in a denial of the renewal license. Making a false statement may subject the licensee to
contempt of court.
I am more than 30 days delinquent in complying with a child support order.
I certify under penalty of perjury that I am not subject to any child support order.
N/A

Licensee Signature
Form Number (445104) (revised 2-2014)

Date
Page 11 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME HEALTH AGENCY ONLY
LICENSED OR REGISTERED EMPLOYEES. List ALL licensed, certified and contractual employees. List
at least ONE contracted employee for each applicable specialty (PT, OT, SP, or MSW). FOR HOME
HEALTH AIDE, PROVIDE INITIALS OF EMPLOYEE , DO NOT INCLUDE SOCIAL SECURITY NUMBER. If
home health aide services are provided by Registered Nurses or Licensed Practical Nurses, please indicate by
placing a pound sign (#) in front of the initials of the person providing the services.
F/T=Full Time, P/T=Part Time and Contract=Contractual Employees.
Job Title/Name

License Number

Expiration Date

F/T

P/T

Administrator Name

Agency Supervisor Name

License Number

Job/Title

Expiration Date

Contract

Please copy and attach additional pages as needed.
Form Number (445104) (revised 2-2014)

Page 12 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME SERVICES/HOME NURSING ONLY
LICENSED OR REGISTERED EMPLOYEES.

List ALL licensed, certified and contractual employees.

F/T=Full Time, P/T=Part Time and Contract=Contractual Employees. FOR CERTIFIED NURSE AID OR
HOMEMAKER, PROVIDE INITIALS OF EMPLOYEE, DO NOT INCLUDE SOCIAL SECURITY NUMBER.

Job Title

License Number

Expiration Date

F/T

P/T

Agency Manager Name

Nursing Supervisor (For Home Nursing Only)
Contract

Form Number (445104) (revised 2-2014)

Page 13 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME NURSING/HOME SERVICES PLACEMENT ONLY
List ALL licensed, certified registry persons. FOR HOMEMAKER OR CERTIFIED NURSE AIDE, PROVIDE INITIALS OF
REGISTRY PERSON.

Job Title

License Number

Expiration Date

Agency Manager Name

Form Number (445104) (revised 2-2014)

Page 14 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME HEALTH/HOME SERVICES/HOME NURSING AGENCY ONLY
Please remember to include a copy of the employee's current Illinois license. If you have submitted a change during the
reporting year and received an approval letter from the Illinois Department of Public Health, it is not considered a change
with this application.

AFFIDAVIT
Please include a copy of each of the following employee's current Illinois license, if applicable.
This is to attest that the following named staff members serve in the position indicated. Please be sure to
check the change/no change box for each position.
It is NOT necessary to complete a qualification review form if there has been no change.
Home Health
Administrator

Change

No Change

Change

No Change

Change

No Change

Change

No Change

Change

No Change

Name of Administrator
Home Health
Agency Supervisor
Name of Agency Supervisor

Social Worker
Name of Social Worker
Social Worker's
Assistant
Name of Social Worker's Assistant

Home Services/Home
Nursing
Agency Manager
Name of Agency Manager

Authorized Agent Signature
Attached are the completed qualification review forms and current Illinois license(s) for the above
change(s).
Form Number (445104) (revised 2-2014)

Page 15 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME HEALTH AGENCY ONLY
Attachment A - Administrator Qualification Review Form
Home Health Agency Name
Address
City

State

ZIP Code

Administrator Information
Last Name

First Name

Middle Initial

Address
City

State

Daytime Phone Number

ZIP Code
Extension

Check one of the following categories. Section 245.20 "Home Health Agency Administrator" requires that the administrator
must be one of the following:
Physician

Registered Nurse

Individual who meets the requirements for a public health administrator as defined in 77 IL Adm. Code 660.310
Individual with at least one year supervisory or administrative experience in home health care or in a related health program
Indicate the highest educational level obtained:
High School
ADN
Diploma R.N.
B.S.N.
B.A.
B.S.
Master's
Doctorate
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.

M.D.

Name of College
Address of College
City
Date of Graduation

State

ZIP Code

State

ZIP Code

Specialty/Degree

Name of College
Address of College
City
Date of Graduation

Specialty/Degree

Please list the high school attended, the address, and date of graduation.
Name of High School

Date of Graduation

Address of High School
City
Form Number (445104) (revised 2-2014)

State

ZIP Code
Page 16 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
List applicable professional licenses, registrations and/or certifications currently held with the license number,
date of expiration and state that issued the license, registration or certification. ATTACH A COPY OF YOUR
CURRENT ILLINOIS LICENSE IF APPLICABLE. YOUR CURRENT EMPLOYER MUST BE THE AGENCY
IDENTIFIED IN THIS APPLICATION. Please also include a letter of intentions with this application (the
applicant must write a letter stating that if he/she will be working part time elsewhere, as well as for
this agency, both agencies are aware of the situation, and it presents no conflict of interest).

Describe your relevant work experience for the last five years.

(1) List your most recent position with THIS AGENCY FIRST and work backward.
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Describe the administrative and financial functions performed for each position, with each agency, that qualify you to
function as the administrator of a home health agency.
(4) Include the names, addresses and telephone numbers of organizations.
You may use an additional sheet of paper to complete this section.
this portion of the form.

Resumes are not accepted in lieu of completion of

Current Employer Name
Address of Current Employer
City

State

Starting (month and year)

Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Previous Employer Name
Address of Previous Employer
City

State

Starting (month and year)

Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Attachment A - Administrator Qualification Review Form Page 2
Form Number (445104) (revised 2-2014)

Page 17 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Previous Employer Name
Address of Previous Employer
City

State

Starting (month and year)

ZIP Code

Ending (month and year)

Total Hours Worked Weekly

Duties

Have you ever been convicted of a criminal offense?

Yes

No

Are there any pending or administratively resolved issues concerning your professional license
in Illinois or in another state?
Yes

No

If you answered “yes” to either or both of the above statements, please describe the criminal offense and/or the
pending or administratively resolved licensure issues in detail, including the state of administrative action
[Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary for the explanation.

I signify that the information contained in this form is true and correct to the best of my knowledge and belief. I
realize that misrepresentation of this information at any time may be cause for denial of this application, or
future revocation of a license.

Signature of Applicant (Original Only)

Date Signed

Attachment A -Administrator Qualification Review Form Page 3
Form Number (445104) (revised 2-2014)

Page 18 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
HOME HEALTH AGENCY ONLY
Attachment B - Agency Supervisor Qualification Review Form

Section 245.30 of the 77 Illinois Administrative Code requires this position to be filled by an individual who is a registered nurse who has
completed a baccalaureate degree program and has at least one year of nursing experience as a Bachelors of Science of Nursing; or a
registered nurse without a baccalaureate degree, who has at least three years of nursing experience as an Registered Nurse within the last
five years (two of those years in a home health agency, a community health program caring for the sick, or a family centered nursing
program in a community health agency). Section 245.20 defines a registered nurse as a person currently licensed as an Registered Nurse
under the Illinois Nursing Act.

Home Health Agency Name

Address
City

State

ZIP Code

Agency Supervisor Information
Last Name

First Name

Middle Initial

Address
City

State

ZIP Code

Daytime Phone Number (include area code and extension)
Section 245.30 requires that the agency supervisor must be a registered nurse.
Indicate the highest educational level obtained
ADN
Diploma R.N.
B.S.N.
B.A.
B.S.
Master's
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.

Doctorate

Name of College
Address of College
City
Date of Graduation

State

ZIP Code

State

ZIP Code

Specialty/Degree

Name of College
Address of College
City
Date of Graduation

Specialty/Degree

Please list the high school attended, the address, and date of graduation.
Name of High School

Date of Graduation

Address of High School
City
Form Number (445104) (revised 2-2014)

State

ZIP Code
Page 19 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
List applicable professional licenses, registrations and/or certifications currently held with the license number,
date of expiration and state that issued the license, registration or certification. ATTACH A COPY OF YOUR
CURRENT ILLINOIS LICENSE IF APPLICABLE. YOUR CURRENT EMPLOYER MUST BE THE AGENCY
IDENTIFIED IN THIS APPLICATION. Please include a letter of intentions with this application (the agency
supervisor position is required to be full time. Provide documentation that the applicant is resigning
present employment, or if working part time elsewhere, provide documentation that the applicant's other
employment is outside the agency's hours of operation).

Describe your relevant work experience for the last five years.

(1) List your most recent position with THIS AGENCY FIRST and work backward.
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Describe the administrative functions performed for each position, with each agency, that qualify you to function as the
agency supervisor of a home health agency.
(4) Include the names, addresses and telephone numbers of organizations
You may use an additional sheet of paper to complete this section. Resumes are not accepted in lieu of completion of this
portion of the form.

Current Employer Name
Address of Current Employer
City

State

Starting (month and year)

Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Previous Employer Name
Address of Previous Employer
City

State

Starting (month and year)

Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Atttachment B-Agency Supervisor Qualification Review Form Page 2
Form Number (445104) (revised 2-2014)

Page 20 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Previous Employer Name
Address of Previous Employer
City
Starting (month and year)

State

ZIP Code

Ending (month and year)

Total Hours Worked Weekly

Duties

Have you ever been convicted of a criminal offense?

Yes

No

Are there any pending or administratively resolved issues concerning your professional license
in Illinois or in another state?
Yes

No

If you answered “yes” to either or both of the above statements, please describe the criminal offense and/or the

pending or administratively resolved licensure issues in detail, including the state of administrative action
[Section 245.130 b) 2]. You may attach an additional sheet of paper if necessary for the explanation.

I signify that the information contained in this form is true and correct to the best of my knowledge and belief. I
realize that misrepresentation of this information at any time may be cause for denial of this application, or
future revocation of a license.

Signature of Applicant (Original Only)

Date

Attachment B - Agency Supervisor Qualification Review Form Page 3
Form Number (445104) (revised 2-2014)

Page 21 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application

HOME HEALTH ONLY - If Applicable
Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form

Attachment D must be completed for each social worker and social work assistant used by your home health
agency, whether directly employed or employed by contract. Section 245.20 of the 77 Illinois Administrative
Code 245 requires that the medical social worker be a licensed social worker/clinical social worker under the
Clinical Social Work and Social Work Practice Act.
Before forwarding Attachment D to the social worker for completion, please fill in the name, address and city of
your home health agency at the top of the form.
The person(s) completing Attachment D also should appear on the (Licensed or Registered Employees)
page for Home Health and check F/T, P/T or contract.

Home Health Agency Name
Address
City

State

ZIP Code

Medical Social Worker Information
Last Name

First Name

Middle Initial

Address
City
Daytime Phone Number

Form Number (445104) (revised 2-2014)

State

ZIP Code
Extension

Page 22 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
THE FOLLOWING TO BE COMPLETED BY MEDICAL SOCIAL WORKER
Section 245.20 requires that the medical social worker be a licensed social worker/clinical social worker under
the Clinical Social Work and Social Work Practice Act.
List applicable professional licenses, registrations and/or certifications currently held. Attach a copy of your
current Illinois license.

Date MSW Degree Awarded (if applicable)

Date of Initial License

Expiration Date of Current License

State of Issuance

Name of College

Date of Graduation

Address of College
City

State

ZIP Code

Specialty Degree

Describe your relevant work experience to meet the requirements of Section 245.20
Employer Name
Address of Employer
City
Starting (month and year)

State
Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Employer Name
Address of Employer
City
Starting (month and year)

State
Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

IF YOU ARE A MEDICAL SOCIAL WORKER, PROCEED TO THE SIGNATURE BLOCK AND SIGN AT THE
BOTTOM OF PAGE FOUR.
Attachment D - Medical Social Worker/Social Work Assistant Work Qualification Review Form Page 2
Form Number (445104) (revised 2-2014)

Page 23 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application

HOME HEALTH AGENCY ONLY
THE FOLLOWING SECTION MUST BE COMPLETED BY THE SOCIAL WORK ASSISTANT
Section 245.20 requires that the social work assistant have a baccalaureate degree in social work, psychology,
sociology or related field and at least one year of social work experience in a health care setting. For persons initially
licensed by a state or seeking initial qualifications as a social work assistant prior to December 31, 1977, refer to 77 Illinois
Administrative Code.
Please list the college(s) attended, the address, date of graduation, specialty and degree obtained.
Name of College
Address of College
City
Date of Graduation

State

ZIP Code

Specialty/Degree

Describe your relevant work experience to meet the requirements of Section 245.20
Employer Name
Address of Employer
City
Starting (month and year)

State
Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Employer Name
Address of Employer
City
Starting (month and year)

State
Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form Page 3
Form Number (445104) (revised 2-2014)

Page 24 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application

Section 245.40 requires a social work assistant to be under the supervision of a social worker (social worker
as defined in Section 245.20). Both social work assistant and supervising licensed social worker should
complete Page 1 of Attachment D.

Name of licensed social worker providing supervision (if applicable)

I signify that the information contained in this form is true and correct to the best of my knowledge and belief. I
realize that misrepresentation of this information at any time may be cause for denial of this application, or
future revocation of a license.

Signature of Medical Social Worker Applicant (Original Only)

Date

Signature of Social Worker Assistant (if applicable) (Original Only)

Attachment D - Medical Social Worker/Social Work Assistant Qualification Review Form Page 4
Form Number (445104) (revised 2-2014)

Page 25 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
ALL AGENCIES EXCEPT HOME HEALTH
Attachment E-Agency Manager Qualification Review Form
If the agency is applying for more than one type of agency, complete an additional Attachment E form for each manager.
Home Nursing Agency Name
Home Service Agency Name
Address
City

State

ZIP Code

Agency Manager Information
Last Name

First Name

MI

Address
City

State

ZIP Code

Daytime Phone Number (include area code and extension)

See Section 245.30 for the requirements for the agency manager

Form Number (445104) (revised 2-2014)

Page 26 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
List applicable professional licenses, registrations and/or certifications currently held with the license number, date
of expiration and state that issued the license, registration or certification. ATTACH A COPY OF YOUR CURRENT
ILLINOIS LICENSE IF APPLICABLE. YOUR CURRENT EMPLOYER MUST BE THE AGENCY IDENTIFIED IN
THIS APPLICATION.

Describe your relevant work experience for the last five years.

(1) List the agency this application applies to as CURRENT employer, and work backwards. For INITIAL application, start date can be "upon
licensure." Provide intentions at any other positions you may hold (i.e., resigning upon licensure, working part-time, if so how many hours per
week).
(2) Give the starting and ending dates (month and year) for each employment and the weekly hours worked.
(3) Describe the administrative and financial functions performed for each position with each agency that qualifies you to function as the
agency manager of a home services/home nursing agency, home services placement agency, home nursing placement agency.
(4) Include the names, addresses and telephone numbers of organizations.
You may use an additional sheet of paper to complete this section. Resumes are NOT accepted in lieu of completion of this portion of the
form.

Current Employer Name
Address of Current Employer
City

State

Starting (month and year)

Ending (month and year)

ZIP Code

Total Hours Worked Weekly

Duties

Previous Employer Name
Previous Employer Address
City

State

Starting (month and year)

Ending (month and year)

ZIP Code

Total Hours Worked Weekly

Duties

Attachment E - Agency Manager Review Form Page 2
Form Number (445104) (revised 2-2014)

Page 27 of 28

State of Illinois
Illinois Department of Public Health
Home Health, Home Services, Home Nursing Agency
Renewal/Change of Ownership Licensure Application
Previous Employer Name
Previous Employer Address
City

State

Starting (month and year)

Ending (month and year)

ZIP Code
Total Hours Worked Weekly

Duties

Have you ever been convicted of a criminal offense?

Yes

No

Are there any pending or administratively resolved issues concerning your professional license in Illinois or in another state?
Yes

No

If you answered "yes" to either or both of the above statements, please describe the criminal offense and/or the
pending or administratively resolved licensure details in detail, including the state of administrative action (Section
245.130b)2). You may attach an additional sheet of paper if necessary for the explanation.

I signify that the information contained in this form is true and correct to the best of my knowledge and belief. I
realize that misrepresentation of this information at any time may be cause for denial of this application, or future
revocation of a license.

Signature of Applicant (Original Only)

Date

ATTACH A COPY OF YOUR CURRENT ILLINOIS LICENSE, IF APPLICABLE

Attachment E - Agency Manager Qualification Review Form Page 3

Form Number (445104) (revised 2-2014)

Page 28 of 28



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