Application Forms

Section 2060.215  Application Forms a)         An application for a new license, to relocate a facility, or to add an additional level of care or population to an existing license shall be made on forms supplied by DHS/SUPR. The application requires, at a minimum, a completed Substance Use Disorder Services Application for Intervention/Treatment License, and applicable attachments, which may include the following: 1)         IRS form W-9 and the letter from the IRS. 2)         Documentation from the Illinois Secretary of State or County Clerk, as applicable. 3)         Schedule A. 4)         If applicable, Board of Directors information. 5)         Organization Chart. 6)         Schedule E. 7)         Schedule L. 8)         Schedule C and documented proof of compliance with all applicable zoning and local building ordinances. 9)         If applicable, the most recent accreditation survey. 10)       Narrative description. 11)       For treatment services, as applicable, copies of linkage agreements. 12)       If applicable, for DUI evaluation and risk education only, copies of letters of agreement with circuit courts. 13)       For recovery homes only, copies of linkage agreements. 14)       For recovery homes only, copy of an operating budget. 15)       For recovery homes only, documentation of fire, hazard, liability and other insurance coverages appropriate to the administration of a recovery home. 16)       If applicable, a copy of the Medicaid Certification issued by the DHS Division of Mental Health pursuant to 59 Ill. Adm. Code 132. 17)       If applicable, proof of registration as a religious or charitable organization. b)         The forms referenced in subsection (a) are obtained electronically at: http://www.dhs.state.il.us/OneNetLibrary/27896/documents/By_Division/OASA/2020/Substance_Use_Disorder_Services_Application.pdf . c)         The application shall be signed by at least one representative vested with authority to act on behalf of the organization.