Section 518.1155 Application for Annual License Renewal

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

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.