Certification Packet

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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

Adult Day Service
A separate application must be submitted for each Adult Day Service site.
- Application for Adult Day Service
Automated Medication Dispenser (AMD) Service

Emergency Home Response Service
- Emergency Home Response Service Application (Revised 08/15)
In-Home Service
- A separate application must be submitted for each Planning and Service Area (PSA) in which services will be provided. For geographic information, refer to the PSA Map, the Chicago City Map and the Suburban Cook County Map
- In-Home Service Application Instructions
- EVV Standards
- Applications for In-Home Service for PSA 01 through PSA 13

Return your completed certification packet to:

**This is for EHRS and AMD only. Other applications are filed online.**

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 start. started.

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

Thank you for your interest in becoming a service provider under the Community Care Program!