Fill Out Your 445103 Form

What is the 445103 form used for?

The 445103 form is the Initial Licensure Application for Home Health, Home Services, and Home Nursing Agencies in Illinois. It is a mandatory document that applicants must complete in order to operate as such agencies within the state. This application enables the Illinois Department of Public Health to evaluate the agency's compliance with applicable licensing laws and regulations.

What fees are associated with the 445103 form?

Fees vary depending on the type of agency being licensed. A single home health agency incurs a $25 fee, while both a home nursing agency and a home service agency will cost $1,500 each. Home nursing placement and home services placement agencies are charged a fee of $500 each. If applying for multiple licenses, the applicant must pay the higher fee applicable to their specific agency types.

Where should the completed application and fees be sent?

Applicants must send the completed 445103 form along with any necessary attachments and the respective licensing fee to the Illinois Department of Public Health at the following address: Health Care Facilities and Programs Section, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761-0001. Ensure that the check or money order is made payable to the Illinois Department of Public Health.

Are there specific instructions for filling out the form?

Yes, there are detailed instructions included with the form. It is crucial for applicants to type the application using Adobe if possible. If completing it in handwriting, careful attention must be paid to drop-down boxes and other specific areas that require accurate information. Additionally, each agency type requires different pages to be filled out, and this must be adhered to.

What happens if incorrect information is provided in the application?

Providing incorrect information can delay the review process of your application or potentially result in the rejection of the application altogether. It is important to thoroughly review all information before submission. A declaration affirming the accuracy of the information must be signed by the agency administrator or manager.

Can more than one agency type be applied for using this form?

Yes, applicants can apply for multiple agency types, but they must complete the form sections relevant to each type. Be aware that the fees associated with the application will then reflect the most expensive licensing fee among the types being applied for if there's overlap.

Do applicants need to retain a copy of the submitted application?

Absolutely. It is recommended that applicants keep a copy of the completed application for their own records. This will serve as a reference for any future communications or inquiries regarding the application status and is helpful for potential audits or renewals.

What should be done if an applicant is part of a corporation?

If the agency is a corporation, the application requires detailed information regarding stockholders and the governing body. Applicants must disclose the number of shares and percentage held by stockholders with more than 5 percent ownership, as well as the names and addresses of the governing body members. This information demonstrates the agency’s organizational structure and compliance with state regulations.

Is there any specific information required for ownership disclosure?

Yes, the application requires information on the legal owner of the agency, including their address and contact details. If the organization is a sole proprietorship, additional declarations must be completed. This requirement ensures accountability and transparency regarding the ownership of the agency.

When completing the Illinois Department of Public Health's 445103 form for an initial licensure application, individuals often make several key mistakes. Being aware of these errors can save time and streamline the application process.

First and foremost, many applicants neglect to read the instructions thoroughly before starting the form. The application specifically advises reviewing the Home Health, Home Services, and Home Nursing Agency Licensing Rules and Regulations. This detail is critical, as understanding the guidelines ensures that applicants provide the necessary information required by law. Failing to do so can lead to incomplete applications or misunderstandings regarding required attachments and fees.

Secondly, applicants frequently overlook the importance of selecting the correct agency type from the drop-down list provided within the form. If an applicant mistakenly identifies their agency as a home health agency instead of a home services agency, it can lead to substantial delays. Each agency type has distinct requirements, and selecting the incorrect one necessitates starting the application process over again.

Another common mistake involves the completion of the affidavit of agreement section. Applicants must ensure that this section is signed by the agency administrator or manager. In some instances, forms are submitted without the necessary original signature. An unsigned application can be deemed incomplete, resulting in rejection and further delays in obtaining the license.

Lastly, an error that can significantly impact the application process is the failure to include the correct licensing fee. Different agency types come with different fee structures, and applicants often miscalculate which fee applies to their situation. The need to enclose a check or money order made payable to the Illinois Department of Public Health is emphasized in the instructions. Omitting this payment not only delays the processing time but also creates additional obstacles in getting the application reassessed.

When applying for the Home Health, Home Services, and Home Nursing Agency Initial Licensure Application using form 445103, there are several other documents that can support your application process. Each document serves a distinct purpose and may be required or beneficial for compliance and operational success. Below is a list of commonly associated forms and documents:

• License Renewal Application: This form is submitted by existing licensed agencies seeking to renew their licenses. It ensures that all operational standards are met and maintained according to state regulations.
• Ownership Disclosure Statement: Required to detail the ownership structure of the agency. This document includes information about all owners, stakeholders, and any changes in ownership since the last application.
• Staffing and Personnel Records: A compilation of documents that verify staff qualifications, including copies of licenses, resumes, and background check results. These records help demonstrate that the agency employs qualified staff members.
• Compliance Plan: This is a strategic document outlining how the agency intends to comply with state laws and regulations. It includes policies for patient care, safety, and administrative procedures.
• Financial Viability Statement: A document demonstrating the agency’s financial stability, including bank statements, profit and loss statements, and other financial documentation. This reassures regulators of the fiscal health of the organization.
• Inspection Reports: Any previous inspection reports from health department visits should be included. These reports can show past compliance, or any issues that have been resolved and how corrective actions were implemented.

These documents not only help ensure your application is complete but also show commitment to operating within legal and regulatory frameworks. Being prepared with the right paperwork can streamline the application process, reducing delays and enhancing your agency's readiness for licensure.

• Form 990 - Return of Organization Exempt from Income Tax: This form is used by tax-exempt organizations to provide information about their annual financial activities. Similarly to the 445103 form, it requires disclosure of various details about the organization, including ownership information and operational structure.

• CMS 855A - Medicare Enrollment Application: This application is essential for healthcare providers seeking to enroll in Medicare. Like the 445103 form, it mandates careful completion of information regarding agency ownership, location, and operational details to obtain necessary licensing.

• Illinois Business Registration Application: Businesses in Illinois must submit this form to operate legally. Just as with the 445103 application, it requires information about the owners and the structure of the business, reflecting the same need for transparency in operations.

• Form 501(c)(3) Application for Recognition of Exemption: Non-profit organizations use this form to apply for federal tax-exempt status. Similar to the 445103, it gathers detailed information about the organization’s governance and purpose, promoting compliance with relevant regulations.

• State License Application for Adult Day Care Providers: This application is required for adult day care services, asking for similar information regarding ownership and governance structures, thus aligning with the comprehensive information request of the 445103 form.

• Application for Health Facility License (State of Illinois): This form is used to license various health facilities. Just like the 445103 form, it collects information on the facility's operations, ownership, and compliance with state health regulations.

• Business Entity Registration with the Secretary of State: This registration is necessary for a business to operate, requiring information about ownership and operational structure. Similar to the 445103 form, it ensures that entities comply with state laws and regulations.

• Do review the Home Health, Home Services, and Home Nursing Agency Licensing Rules and Regulations before starting.
• Do ensure to pay the correct licensing fee associated with your application type.
• Do retain a copy of the completed application for your records.
• Do type the application using Adobe to avoid errors related to drop-down selections.
• Do verify that all required fields are completed accurately and are legible.

• Don’t submit the application without the necessary attachments or fees included.
• Don’t ignore the instructions on how to correctly fill out the form.
• Don’t leave any sections blank unless explicitly noted as optional.
• Don’t use white-out or erasers; corrections must be clear and neat.
• Don’t forget to check for any additional requirements specific to your agency type.

• Misconception 1: The 445103 form is overly complicated.

Many people feel that the application process is daunting. While it does require thorough information, clear guidance is provided throughout the form, making it manageable for applicants.

• Misconception 2: Only expensive agencies need to apply.

Some individuals believe that only larger, costly agencies require licensing. In reality, any agency providing home health services in Illinois must complete the 445103 form, regardless of size or budget.

• Misconception 3: The licensing fees are a one-time charge.

New applicants might think that they only need to pay the licensing fee when submitting the application. However, licensing fees may recur annually, depending on the type of agency and its operations.

• Misconception 4: Filling out the application by hand is just as easy as typing it.

Some people assume that completing the application by hand is acceptable. In fact, not using Adobe to type the application can lead to mistakes that complicate the process. It's best to type the information electronically.

• Misconception 5: You can skip parts of the form if you think they're unnecessary.

A common error applicants make is believing that they can leave out information they find irrelevant. It's essential to complete all required sections to comply with state regulations, even if they seem unimportant.

• Misconception 6: Only health care professionals can fill out the 445103 form.

Some think that only licensed professionals can complete the application. Anyone knowledgeable about the agency's operations and ownership can fill it out, as long as they can provide accurate information.

1. Understand the Licensing Fees: The application requires different fees depending on the type of agency. For instance, a single home health license costs $25, while home nursing or services agencies each cost $1,500. Be sure to include the correct fee with your application.

2. Complete All Necessary Pages: Depending on the type of agency you are applying for, different pages of the 445103 form must be filled out. Ensure you check the requirements carefully to avoid delays in processing your application.

3. Provide Accurate Information: It’s essential to ensure that all the information you write is accurate and complete. The agency requires correct details about ownership, contact information, and governing body details.

4. Retain a Copy: After submitting the application, keep a copy for your records. This retention is crucial should you need to reference your submission in the future.

5. Use Adobe for Online Submission: If you plan to fill out the application electronically, use Adobe to complete it. If you choose to write it out, be mindful of the drop-down boxes and ensure you fill in all required sections correctly.