Form XXXXX Renewal Application for Community-Based Residential Rehabilitation Center License - Illinois

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State of Illinois
Illinois Department of Public Health
RENEWAL APPLICATION FOR COMMUNITY-BASED RESIDENTIAL
REHABILITATION CENTER LICENSE
$500 Application Fee Attached
C-BRR ID Number:
$100 for each C-BRR care bed
- DEPARTMENT USE ONLY-
Total $
Pursuant to Section 265 of the Alternative Health Care Delivery Act [210 ILCS 3] and the rules of the Illinois Department of Public Health entitled "Community-
Based Residential Rehabilitation Center Demonstration Program Code" (77 Ill. Adm. Code 220)
NAME/ADDRESS OF APPLICANT
1.
Name
Address
City
State
Zip Code
County
Telephone Number (Including Area Code)
2. LOCATION OF COMMUNITY-BASED RESIDENTIAL REHABILITATION CENTER
Name
Address (if in a freestanding building)
City
County
State
Zip Code
Telephone Number (Including Area Code)
3.
Number of C-BRR Care Beds
(Attach listing if multiple sites are used. Include address and number of beds)
4.
Name and address of the Illinois Registered Agent or other individual(s) authorized to receive Service of Process for the
facility.
Name(s) of Registered Agent(s)
Address
IMPORTANT NOTICE
THIS STATE AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY
PURPOSE AS OUTLINED UNDER 210 ILCS 3. DISCLOSURE OF THIS INFORMATION IS MANDATORY. THIS HAS BEEN APPROVED BY
THE FORMS MANAGEMENT CENTER.
Form Number XXXXX
Page 1 of 2
State of Illinois
Illinois Department of Public Health
RENEWAL APPLICATION FOR COMMUNITY-BASED RESIDENTIAL
REHABILITATION CENTER LICENSE
$500 Application Fee Attached
C-BRR ID Number:
$100 for each C-BRR care bed
- DEPARTMENT USE ONLY-
Total $
Pursuant to Section 265 of the Alternative Health Care Delivery Act [210 ILCS 3] and the rules of the Illinois Department of Public Health entitled "Community-
Based Residential Rehabilitation Center Demonstration Program Code" (77 Ill. Adm. Code 220)
NAME/ADDRESS OF APPLICANT
1.
Name
Address
City
State
Zip Code
County
Telephone Number (Including Area Code)
2. LOCATION OF COMMUNITY-BASED RESIDENTIAL REHABILITATION CENTER
Name
Address (if in a freestanding building)
City
County
State
Zip Code
Telephone Number (Including Area Code)
3.
Number of C-BRR Care Beds
(Attach listing if multiple sites are used. Include address and number of beds)
4.
Name and address of the Illinois Registered Agent or other individual(s) authorized to receive Service of Process for the
facility.
Name(s) of Registered Agent(s)
Address
IMPORTANT NOTICE
THIS STATE AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY
PURPOSE AS OUTLINED UNDER 210 ILCS 3. DISCLOSURE OF THIS INFORMATION IS MANDATORY. THIS HAS BEEN APPROVED BY
THE FORMS MANAGEMENT CENTER.
Form Number XXXXX
Page 1 of 2
State of Illinois
Illinois Department of Public Health
RENEWAL APPLICATION FOR COMMUNITY-BASED RESIDENTIAL
REHABILITATION CENTER LICENSE
5.
List the name(s) and title(s) of person(s) under whose management or supervision the C-BRR beds will be operated.
Name
Title
6.
VERIFICATION
I (we) swear or affirm that this application and accompanying documents are true and complete. I (we) further certify that
I (we) have knowledge of and understand the action required to comply with the Act and licensing requirements.
Signed
Signed
Title
Title
Signed and Sworn (or attested) to before me this
day of
20
Notary Public
My commission expires
20
SUBMIT APPLICATION AND FEE TO:
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
DIVISION HEALTH CARE FACILITIES AND PROGRAMS
525 WEST JEFFERSON STREET, 4th Floor
SPRINGFIELD, ILLINOIS 62761
Form Number XXXXX
Page 2 of 2

Download Form XXXXX Renewal Application for Community-Based Residential Rehabilitation Center License - Illinois

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