Section 205.120  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)         The initial application 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 copy of its certificate of incorporation,

B)        A list of the title, name, and address of each of its corporate officers,

C)        A list of the name and address of each of its shareholders holding more than five percent 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 in the last five years.

6)         The name, address, telephone number, education, experience, credentials and any professional licensure or certification of the following persons:

A)        Administrator.

B)        Medical Director.

C)        Supervising Nurse.

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 narrative description of the facility including but not limited to interviewing, examination, surgical and recovery room facilities.

10)       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)       Documentation of compliance with Section 205.350 of this Part.

12)       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)       A copy of the organizational plan of the facility (see Section 205.220).

14)       Schematic architectural plans.

15)       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)       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)

(Source:  Amended at 18 Ill. Reg. 17250, effective December 1, 1994)