Application Forms

Section 996.500  Application Forms a)         Each companion animal owner or feral cat colony manager shall submit an Application/Eligibility Voucher form to the Department.  This form includes the consent form (see Section 996.300(a)), the veterinarian certificate for reimbursement (see Section 996.700(c)), and the eligibility voucher (see Section 996.400(d)). 1)         The companion animal owner or feral cat colony manager shall include his or her name and address, the type of eligibility claimed (SNAP, SSDI or feral cat colony manager), a description of the animal or animals to be sterilized, and a signature and date on the consent form, which is Part I of the Application/Eligibility Voucher. 2)         Upon approval, the Department will affix an approval code, an issue date, and an authorization stamp to Part III of the form.  The approved and stamped form is the eligibility voucher (see Section 996.400(d)). 3)         After an approved eligibility voucher has been returned, the companion animal owner or feral cat colony manager shall schedule the sterilization procedure with a participating veterinarian.  After the sterilization procedure is performed, the veterinarian shall include his or her name, the name and address of the clinic, the date of the sterilization procedure, the specific immunizations administered, and whether a co-payment was received (see Section 996.700) on Part II of the Application/Eligibility Voucher.  The veterinarian and the companion animal owner or the feral cat colony manager shall also sign and date Part II of the form, which is the veterinarian's certificate for reimbursement. b)         Each participating veterinarian shall submit a Veterinarian Application/Agreement to Participate (Agreement to Participate) form to the Department available on its website at http://www.idph.state.il.us/pdf/ Spay_Neuter_Veterinarian_Participation.pdf. 1)         The veterinarian shall include his or her name, the name and address of the veterinary practice, his or her Illinois veterinary medicine license number, and contact information.  The veterinarian shall also indicate which animal or animals (dogs, domestic cats or feral cats) he or she will accept under this program. 2)         The veterinarian shall sign and date the Agreement to Participate on the form.  This Agreement to Participate details the veterinarian's duties and responsibilities under the Act and this Part.