86 Ill. Adm. Code 535.120
Certification by Distribution Agent
Section 535
Section 535.120Â
Certification by Distribution Agent
a)Â Â Â Â Â Â Â Â A Nursing Home Grant Assistance Certification
("Certification") shall consist of two forms issued by the
Department:Â Form NH-1, Nursing Home Grant Assistance Certification and Form
NH-2, Individuals Eligible For Grant. A Certification is not timely filed
unless both Form NH-1 and Form NH-2 are filed with the Department on or before
the due date for the Certification.
b)Â Â Â Â Â Â Â Â On or before the last day of September, December, March and
June a nursing home that is a distribution agent under the Act shall file with
the Department Form NH-1 of the Certification. Form NH-1 of the Certification
shall contain the following information:
1)Â Â Â Â Â Â Â Â the total number of occupied bed days during the quarter,
multiplied by $1.00;
2)Â Â Â Â Â Â Â Â the total amount of the fee due to the Department.
c)Â Â Â Â Â Â Â Â On or before the last day of September, December, March and
June a nursing home that is a distribution agent under the Act shall file with
the Department Form NH-2 of the Certification. Form NH-2 of the Certification
shall contain the following information:
1)        Distribution Agent Information. The Certification shall
contain the name and address of the distribution agent, as well as:
A)Â Â Â Â Â Â Â the number of the license issued to the distribution agent
under the Nursing Home Care Act by the Illinois Department of Public Health;
B)Â Â Â Â Â Â Â the distribution agent's Federal Employer Identification
Number; and
C)Â Â Â Â Â Â Â the distribution agent's Illinois Business Identification
Number.
2)        Total Grant Calculation. The Certification shall disclose,
for the quarter immediately preceding the quarter for which a certification is
filed:
A)Â Â Â Â Â Â Â the name and social security number of each eligible individual
and the total number of eligible individuals for whom a written authorization
has been executed and is maintained on file as required by Section 535.110 of
this Part; and
B)Â Â Â Â Â Â Â the total number of occupied bed days for each eligible
individual included in the Certification, and the total number of occupied bed
days for all eligible individuals.