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Anyone, 6 months of age and older, is eligible to receive the COVID-19 vaccine. Find your nearest vaccination location at

Certification Packet

The certification packet consists of the following documents.

NOTE: Each applicant must submit BOTH a Legal Entity Application and the appropriate Service Specific Application.

1. Legal Entity Application

Complete only one application per Adult Day Service, Automated Medication Dispenser, Emergency Home Response, and/or In-Home Service legal entity.

2. Service Specific Applications

PSA 01; PSA 02; PSA 03; PSA 04; PSA 05; PSA 06; PSA 07;

PSA 08; PSA 09; PSA 10; PSA 11; PSA 12; PSA 13

Return your completed certification packet to:

Illinois Department on Aging
Attn: Office of Service Development and Procurement
One Natural Resources Way, Suite 100
Springfield, IL 62702-1271

*All forms must be completed accurately before processing can be started. 

*Any incomplete packet will be returned. Be sure to maintain a copy for your records.

We appreciate your interest in becoming a service provider under the Community Care Program!