Application for License Renewal

Section 205 Section 205.125  Application for License Renewal 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)