Current through Register Vol. 48, No. 12, March 22, 2024
a) An application for license shall be made
to the Department on forms provided bythe Department (Section 5 of the Act).
The application shall be submitted not less than sixty days prior to the date
of intended operation and shall contain the information required under the Act
and this Part.
b) The initial
application shall include the following information:
1) The names and addresses of all persons who
own the facility, any names under which any of these persons do business, and
the type of ownership of the facility (for example, individual, partnership,
corporation, or association). In addition, a corporation shall submit:
A) A copy of its certificate of
incorporation,
B) A list of the
title, name, and address of each of its corporate officers,
C) A list of the name and address of each of
its shareholders holding more than five percent of the shares.
2) For other than individual
ownership, the name and address of the Illinois Registered Agent or person(s)
legally authorized to receive service of process for the facility.
3) The names and addresses of all persons
under contract to manage or operate the facility.
4) The location of the facility.
5) Information regarding any conviction of
the applicant, or if the applicant is a firm, partnership or association, of
any of its members, or if the applicant is a corporation, of any of its
officers or directors, or of the person designated to manage or supervise the
facility, of a felony, or of two or more misdemeanors involving moral turpitude
in the last five years.
6) The
name, address, telephone number, education, experience, credentials and any
professional licensure or certification of the following persons:
A) Administrator.
B) Medical Director.
C) Supervising Nurse.
7) A list of the medical staff including
name, specialty and license number.
8) A list of all staff personnel including
name, position, education, experience, and any professional licensure or
certification.
9) A narrative
description of the facility including but not limited to interviewing,
examination, surgical and recovery room facilities.
10) A description of services to be provided
by the facility including a list of surgical procedures to be performed and
documentation of the Consulting Committee's approval of the list.
11) Documentation of compliance with Section
205.350 of
this Part.
12) A copy of the
transfer agreement with a licensed hospital within approximately 15 minutes
travel time of the facility or other documentation demonstrating compliance
with Section
205.540(d)
of this Part.
13) A copy of the
organizational plan of the facility (see Section
205.220
).
14) Schematic architectural
plans.
15) Documentation of a
permit as required by the Illinois Health Facilities Planning Act (Ill. Rev.
Stat. 1991, ch. 1111/2, par. 1151 et seq.) [20 ILCS 3960 ].
16) Documentation of compliance with all
applicable local building, utility, and safety codes.
c) The application shall be signed by the
applicant and shall include a verification form acknowledging the application
to be true and complete and certifying that the applicant has knowledge of and
understands the action required to comply with the Act and licensing
requirements. The form shall be verified by a notary public. (Section 5 of the
Act)
d) Thelicense applicationshall
be accompanied by a license fee of $500. (Section 5 of the Act)