77 Ill. Adm. Code 205.120
Application for Initial Licensure
Section 205
Section 205.120Â Application
for Initial Licensure
a)
An application for license shall be made to the Department
on forms provided by
the 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)Â Â Â Â Â Â Â Â The initial application shall include the following information:
1)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â A copy of its certificate of incorporation,
B)Â Â Â Â Â Â Â A list of the title, name, and address of each of its corporate
officers,
C)Â Â Â Â Â Â Â A list of the name and address of each of its shareholders
holding more than five percent of the shares.
2)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â The names and addresses of all persons under contract to
manage or operate the facility.
4)Â Â Â Â Â Â Â Â The location of the facility.
5)Â Â Â Â Â Â Â Â 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)Â Â Â Â Â Â Â Â The name, address, telephone number, education, experience,
credentials and any professional licensure or certification of the following
persons:
A)Â Â Â Â Â Â Â Administrator.
B)Â Â Â Â Â Â Â Medical Director.
C)Â Â Â Â Â Â Â Supervising Nurse.
7)Â Â Â Â Â Â Â Â A list of the medical staff including name, specialty and
license number.
8)Â Â Â Â Â Â Â Â A list of all staff personnel including name, position,
education, experience, and any professional licensure or certification.
9)Â Â Â Â Â Â Â Â A narrative description of the facility including but not
limited to interviewing, examination, surgical and recovery room facilities.
10)Â Â Â Â Â Â 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)Â Â Â Â Â Â Documentation of compliance with Section 205.350 of this Part.
12)Â Â Â Â Â Â 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)Â Â Â Â Â Â A copy of the organizational plan of the facility (see Section
205.220).
14)Â Â Â Â Â Â Schematic architectural plans.
15)Â Â Â Â Â Â Documentation of a permit as required by the Illinois Health
Facilities Planning Act (Ill. Rev. Stat. 1991, ch. 111½, par. 1151 et seq.) [20
ILCS 3960].
16)Â Â Â Â Â Â 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)
The
license application
shall be accompanied
by a license fee of $500.
(Section 5 of the Act)