Section 518.1155  Application for Annual License Renewal

a)         Application for annual license renewal shall be submitted at least 90 days prior to licensure expiration on forms prescribed by the Department.  The application shall include, at a minimum, the following information:

1)         The names, addresses and telephone numbers of all persons who own the facility, any name under which any of these persons does 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 corporation officers; and

B)        A list of the name and address of each of its shareholders holding more than 7.5% of the shares;

2)         For other than individual ownership, the name and address of the Illinois Registered Agent or persons 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 name and exact address of the facility;

5)         The names and addresses of the Administrator, Medical Director and Nurse Manager.  In addition, the education, experience, credentials and any professional licensure or certification of these individuals shall 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.  The facility shall inform the Department of any change in this information at the time that the change occurs;

6)         A list of medical staff, including names and license numbers;

7)         A copy of the organizational plan and description of services if changes have occurred since the last submission; and

8)         Identification of any plans of correction currently in effect as a result of State and federal surveys.

b)         Each renewal application shall be accompanied by a non-refundable license renewal fee of $2000 and proof of compliance with all reports required by the Department.

(Source:  Added at 33 Ill. Reg. 8317, effective June 4, 2009)