Current through Register Vol. 48, No. 12, March 22, 2024
a)
Application for license renewal shall be submitted on forms provided by the
Department. Application for license renewal shall be submitted to the
Department not less than 30 days prior to the expiration date.
b) An application for license renewal 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
list of the title, name and address of each of its corporate
officers.
B) A list of the name and
address of each of its shareholders holding more than 5% 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 during the previous year.
6) The name, address, and telephone number of
the administrator, medical director, and supervising nurse. In addition, the
education, experience, credentials and any professional licensure or
certification of these individuals must also be submitted if this information
was not submitted with the initial application or a prior renewal application
or if this information has changed since the prior submission.
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 list of
surgical procedures being performed at the facility and documentation of the
Consulting Committee's approval of the list.
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) The license renewal
application shall be accompanied by a license renewal fee of $300. (Section 6
of the Act)
