instructions · the home medical equipment and services provider licensing act of 1998 provides for...

INSTRUCTIONS

Purpose

Completingthe Application

Certificate ofInsurance

APPLICATION FOR HOME MEDICAL EQUIPMENT PROVIDER

Mailing Address

The Home Medical Equipment and Services Provider Licensing Act of 1998 provides for thelicensure of entities providing home medical equipment and its services.

1) All information must be accurate and complete. Incomplete applications will not beprocessed and will be returned to you for completion.

2) Information should be typed or printed legibly with black ink.

3) Initial Application for Licensure: Complete questions 1-13 of the application includingeither Section I or II.

4) Change of Ownership: Complete questions 1-13 of the application and Section III.5) Re-Application: (Change of address, change of name of facility or change of person

responsible for day to day operations):(a) Complete questions 1-13 of the application.(b) Complete applicable portion of Sections I-VI.(c) Sign application.

6) Out-of-State Applicants(a) submit Certification of Licensure (CT) completed by the principal state in which the

facility is located, if applicable.(b) submit copy of last inspection report, if applicable.

7) Corporations:(a) attach a copy of the Articles of Incorporation

8) Limited Liability Corporation:(a) attach a copy of the Articles of Organization

9) Certificate: If certified by any recognized accreditation body, attach copy of certificate.

Supporting Document HME-INS must be properly completed and submitted. This the onlyproof of commercial general liability insurance which will be accepted by this Department.

Initial licensure or change of ownership $300Change of address of facility $150Name change of facility $150

A separate license is required for each facility where business is conducted.

Mail the completed application with the fee in the form of a check or money order to:Department of Financial and Professional RegulationATTN:Division of Professional Regulation320 W. Washington Street, 3rd FloorSpringfield, Illinois 62786

For assistance in completing your application call: 217/782-8556

or visit our website at:

www.idfpr.com

Fees

Home MedicalEquipment Providers

Telephone No.

IL486-1856 12/04 (HME-Inst.)

Internet Address

The application which yousubmit is valid for 3 yearsfrom date of receipt.

Original Application Re-application

Illinois In-State Home Medical Equipment Provider License ApplicationIllinois Out-of-State Home Medical Equipment Provider License Application

TO BE COMPLETED BY ALL APPLICANTS

Illinois Department of Financial and Professional Regulation320 West Washington, 3rd Floor, Springfield, Illinois 62786

IL486-1856 12/04 (HME)

License No.:_____________________________________

APPROXIMATE DATE FACILITY WILL BE READY FOR OPERATIONCOMPLETE ONLY IF ILLINOIS IN-STATE FACILITY

SECTION I

SECTION IICOMPLETE ONLY IF OUT-OF-STATE APPLICANT

(Attach copy of HME and/or Pharmacy License, if applicable)

SECTION III

a. State(s) Currently Licensed In

COMPLETE ONLY IF CHANGE OF OWNERSHIP

SECTION V

a. Previous Person Responsible for On-Site Day to Day Operations ofBusiness

COMPLETE ONLY IF CHANGE OF PERSON RESPONSIBLE FORON-SITE DAY TO DAY OPERATIONS

5. PRINCIPAL ADDRESS OF FACILITY (Include Street, City, Stateand ZIP Code)

b. Previous Illinois HME License No. c. Effective Date of Change

SECTION IVCOMPLETE ONLY IF CHANGE OF ADDRESS

a. Previous Address of Facility

b. Current Illinois HME License No. c. Date of Proposed Opening

b. Current Illinois Home MedicalEquipment Provider License No.

c. Effective Date of Change

COMPLETE ONLY IF CHANGE OF NAME OF LICENSED FACILITYSECTION VI

a. Previous Legal Name of Facility

12. SERVICES PROVIDED

FDA# __________________ DOT#________________13b. IF YES, PLEASE PROVIDE:

Oxygen and oxygen delivery systems VentilatorsRespiratory disease management devices, Apnea monitors

excluding compressor driven nebulizersWheelchair seating systemsHospital beds and electronic

computer driven wheelchairs excluding scootersTranscutaneous electrical nerve stimulator (TENS) unitsLow air-loss cutaneous pressure management devicesSequential compression devicesNeonatal home phototherapy devicesEnteral feeding pumpsOther similar equipment

13a. IF OXYGEN IS CHECKED ABOVE:

6. COUNTY

a. Previous Owner Information - Name, Address and FEIN No.

4a. NAME OF PERSON RESPONSIBLE FOR ON-SITE DAY TO DAYOPERATIONS

4b. SOCIAL SECURITY NO.

10. NUMBER OF OFF-SITE STORAGE FACILITIES OR WAREHOUSESUNDER OWNERSHIP OF ABOVE (Attach a separate sheet if needed.)

Individual Limited Liability CompanyPartnership CorporationOther

9. TYPE OF OWNERSHIP

8. ALL TRADE OR BUSINESS (DBA) NAMES USED BYCORPORATION OR LICENSEE

c. Current Illinois License No. d. Effective Date of Change

b. Is this a change of ownership? Yes No

b. License Number(s)

Profession Code

2031. TYPE OF APPLICATION

2. LEGAL NAME OF BUSINESS

NewChange of OwnershipChange of Address

3a. FEIN NUMBER

4c. DATE OF BIRTH

7. PHONE NO. (Include Area Code)

1

IMPORTANT NOTICE: Completion of thisform is necessary for consideration forlicensure under 225 ILCS 51/1 et. seq.(Illinois Compiled Statutes). Disclosure ofthis information is VOLUNTARY. However,failure to comply may result in this form notbeing processed.

Do you transfill oxygen? Yes NoDo you carry over 1000 lbs Yes No

3b. MEDICARE (NSC) ID NUMBER

Change of Name of LicensedFacility

Change of Person Responsiblefor on site Day to Day Operations

11.ACCREDITATION/CERTIFICATION NUMBER (If applicable)

I do solemnly swear or affirm that the answers appearing hereon are true and correct to the best of my knowledge and belief,that I am legally authorized to sign for this business, and complies with all applicable federal and State licensure and regulatoryrequirements; maintains a physical facility and medical equipment inventory (there shall only be one license permitted at eachaddress); establishes proof of commercial general liability insurance, including but not limited to, coverage for products liability andprofessional liability; establishes and provides records of annual continuing education for personnel engaged in the delivery,maintenance, repair, cleaning, inventory control, and financial management of home medical equipment and services; maintainsrecords on all patients to whom it provides home medical equipment and services; establishes equipment management andpersonnel policies; makes life sustaining home medical equipment and services available 24 hours per day and 7 days per week;and complies with any additional qualifications for licensure as determined by rule of the Department.


13. Has applicant, or any names therein listed, ever been convicted in a court of law, hearing, or other administrative procedure withany violation of the laws of the United States or of any individual state, relating to drugs, liquor, poisonous substance or any felonyoffense? !Yes !No (If "Yes," state all particulars, dates, places, and present status on separate sheet.)

TO BE COMPLETED BY ALL APPLICANTS. List below the names and addresses of any other HME facilities in Illinois owned by the applicant.

Name and Address of Each Facility: (Street Address, City, State, ZIP Code & County)

Full name, emergency telephone and social security number of the responsible person for each facility:

Area Code and TelephoneNumber of each facility:

License Number(s)

Date of Birth

Emergency Phone No.License No.

2

Full NameFacility Phone No.

Social Security No.Controlled Substance License No.

1

4

3

2IL486-1856 12/04 (HME)

Type or Print Name of Person Responsible for Day to Day Operations Signature of Person Responsible for Day to Day Operations Date

Date

License No.

Facility Phone No.

Controlled Substance License No.

License No

Facility Phone No.


License No

Facility Phone No.


Date of Birth

Emergency Phone No.

Full Name

Social Security No.

Date of Birth

Emergency Phone No.

Full Name

Social Security No.

Date of Birth

Emergency Phone No.

Full Name

Social Security No.

Legal Nam

e of Business: ____________________________ FEIN

or SS#: _______________ Profession Nam

e: HO

ME M

EDIC

AL EQ

UIPM

ENT

Type or Print Name of Owner or Person Designated to Sign for Firm Signature of Owner or Person Designated to Sign for Firm

I UNDERSTAND THAT FEES ARE NOT REFUNDABLE. My signature above authorizes the Department of Financial andProfessional Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be doneonly if the amount submitted is greater than the required fee hereunder, but in no event shall such reduction be made in an amountgreater than $50.

PARTNERSHIP (If additional space is required, list on a separate sheet.)Partner Name

Percentage of Ownership

SOLE PROPRIETORSHIPOwner Name Date of Birth Social Security No.

Address (Street, City, State, ZIP Code)

CORPORATION (List all officers, directors and shareholders owning 5% or more of outstanding shares.If additional space is needed, use separate sheet.)


3IL486-1856 12/04 (HME)

Social Security No.

Social Security No.

Social Security No.



Date of Birth

Date of Birth

Date of Birth




Partner Name

Partner Name

Name

Name

Name

Name

Name

Name

Name

Name

Name










Legal Nam

e of Business: ____________________________ FEIN

or SS#: _______________ Profession Nam

e: HO

ME M

EDIC

AL EQ

UIPM

ENT

LIMITED LIABILITY COMPANY (List manager or members owning 5% or more of outstanding shares.If additional space is needed, use separate sheet.)

SUPPORTING DOCUMENT

Home Medical Equipment & Services Providers

CERTIFICATION BY LICENSING I HME-CTAGENCY/BOARD

~IIMPORTANT NOTICE: Completion of thisform is necessary for consideration for licensureunder 225 of the Illinois Compiled Statutes.Disclosure of this information is VOLUNTARY.However, failure to comply may result in thisform not being processed. This form has been

approved by the Forms Management Center. I I

APPLICANT: Complete t!!e applicantse~f'0n of this form then fc"ward this forwto the jurisdiction in which you arerequesting certificationbya licensing agency/bgard. You are authorized to photocopy this formasnecessary.

1. LEGAL NAME OF BUSINESS

2. ASSUMED NAME OF BUSINESS OR D/B/A NAME

3. ADDRESS STREET, CITY, STATE, ZIP CODE

4. TELEPHONE NUMBER (Include Area Code)

Area Code (-- -)I hereby authorize

(State to which form is sent)

Financial and Professional Regulation, the information requested below.

to furnish to the Illinois Department of


Type or Print Title of Owner or Person Designated to Sign for Firm

LICENSE NUMBER

Date

DO~OT ~ETU~~SPMPLETEDFORM TO A~~~IS~NThe Illinois DeparjmentofFinancial andProfessionalF1egu/~tion will accept other forms 0certificC!.tion providec{allapplicable infc)rma.!i~n requesJedgn tbis form is containedCertification., Please record N/A in areas which are not applicable.

LICENSE STATUS I DATE LICENSE ISSUED I DATE LICENSE EXPIRES

HAS THIS LICENSE BEEN ENCUMBERED IN ANY

WAY? 0 Yes 0 No

USE REVERSE SIDE OF THIS FORM FOR

TYPE OF ENCUMBERANCE

o Revoked 0 Surrendered

o Suspended 0 RestrictedEXPLANATIONS

o Limitedo Probation

PLEASE ATTACH CERTIFIEDCOPIES OF ALL PERTINENTLEGAL DOCUMENTS.

Has the applicant been convicted under any federal, state or local laws relating to the provisionof home medical equipment and its services? (If yes, please explain.)

Has the applicant furnished any false or fraudulent material in any application made in connectionwith home medical equipment or its services? (If yes, please explain.)

Have any inspections of the applicant resulted in deficiency ratings? (If yes, please explain.)

Has the applicant met all licensing requirements of your state? (If no, please explain.)

DYes

DYes

DYes

DYes

DNo

DNo

DNo

DNo

BOARD SEAL AREA (AFFIX OFFICIAL STATE SEAL OF LICENSINGAGENCY BELOW)

SIGNATURE

IL486-1857 12/04 HME

TITLE

RETURN COMPLETED FORM TO:

Illinois Department of Financial and Professional RegulationDivision of Professional Regulation

P.O. Box 7007Springfield, IL 62791

STATE I DATE

IMPORTANT NOTICE: Completion of this SUPPORTING DOCUMENTform is necessary for consideration for

licensure under 225 of the Illinois Compiled H M E INSStatutes. Disclosure of this information is CERTIFICATION OF INSURANCE -VOLUNTARY. However, failure to complymay result in this form not being processed.This form has been approved by the FormsManagement Center.

APPLICANT: Complete the applicant section of this form, then have your authorized insurance agent complete theremainder of the form. The completed form musfbe submitted WITH your application for licensure.

This is the on/~.!grm whichIyou"eedto submit}f youare<certifyingto £.fJrrent insurance coverageafter the expiration of a previously held policy.

1. NAME OF INSURED HOME MEDICAL EQUIPMENT & SERVICES 2. FEIN (If applicable) 3. SOCIAL SECURITY NUMBERPROVIDER BUSINESS (Must be exactly as it appears on application, (If individual owner)renewal form or license.)

- ---- -- ----4. ADDRESS STREET, CITY, STATE, ZIP CODE (Specific Address of 5. NEW APPLICANTS ONLY

insured's location covered by insurance policy.) REFER TO REFERENCE SHEET. Record profession name and threedigit profession code for which you are making Illinois application.

Home Medical Equipment& Services Provider 2 0 3

Profession Name Profession Code

6. TELEPHONE NUMBER (Where you can be reached during the day) 7. RENEWAL APPLICANTS AND PERSONS VERIFYING CURRENTINSURANCE ONLY.

INDIVIDUAL LICENSE NUMBER - RECORD THE LICENSE NUMBER

Area Code ( ) YOU HOLD (IF APPLICABLE).203 -

I hold commercial general liability insurance in at least the minimum amount of $1,000,000 including, but not limited tocoverage for product liability and professional liability. Under penalties of perjury, I declare that I have examined this form,and to the best of my knowledge, it is true, correct, and complete.


Type or Print Title of Owner or Person Designated to Sign for Firm Date

INSURANCE COMPANY: Complete the following information and return this form to the insured party.

A. NAME OF INSURANCE COMPANY B. NAME OF AUTHORIZED AGENCY

C. INSURANCE COMPANY HOME ADDRESS: D. AGENT'S ADDRESS:STREET, CITY, STATE, ZIP CODE STREET, CITY, STATE, ZIP CODE

E. INSURED'S POLICY NUMBER F. AGENT'S BUSINESS TELEPHONE NUMBER

Area Code ( ) - _

G. EFFECTIVE DATE OF POLICY H. EXPIRATION DATE OF POLICY

__ I __ I I __ I __Month Day Year Month Day Year

If this Policy is terminated prior to its expiration, the Company agrees to give written notice to the Department of Financialand Professional Regulation, Division of Professional Regulation, at least thirty (30) days prior to the effective date ofcancellation.

Signature of Authorized Agent Date

IL486-1858 12/04 (HME)

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