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If you have questions regarding this application, please call: 217-782-7412 or TTY number (for hearing impaired) 800-547-0466. NOTE: Please retain a copy of the application for future reference.
Filing an application is not a guarantee that a license will be issued. If you have questions regarding this application, call 217-782-7412 or TTY number (for hearing impaired) 800-547-0466. NOTE: Retain a copy of the application for future reference.
The new owner shall file an application for license on the renewal/change of ownership application at least 45 days prior to the sale. The Department shall issue a new license to a new owner who meets the requirements for licensure under this Part.
Illinois has partnered with HHAeXchange to help Illinois providers become compliant with state and federal Electronic Visit Verification (EVV) requirements and ensure a simplified, user-friendly, and seamless experience.
Home Health, Home Services, Home Nursing Agency Renewal/Change of Ownership Licensure Application. Form Number (445104) (revised 2-2014) Page 2 of 28. 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.
HHA Renewal/Change of Ownership Licensure Application Form Number (445104) Page 1 of 27 The completed application and appropriate attachments, accompanied by the required $25 license fee made payable to the Illinois Department of Public Health (check or money order), should be sent to: ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Please check if this is a renewal application or a change of ownership. This application deals only with home health services, not private duty or shift work. If the following statement does not apply to the patients served by your agency, this is not the correct application: Patients receive home health services at least once
