a) Applications shall be made on forms provided by the Department. Applications forms may be obtained by writing to:

Illinois Department of Public Health

Division of Health Statistics and Policy Development

535 West Jefferson Street, Second Floor

Springfield, Illinois 62761

b) An application for a permit to operate a life care facility must contain the following:

1. 1) A copy of the proposed form of life care contract to be entered into with residents (Section 4 of the Act).
2. 2) A copy of the letter of credit or escrow agreement as provided by Section 7 of the Act. To allow the Department to determine the provider's compliance with Section 7 of the Act, a complete, detailed written description of any long-term financing of the facility must be submitted with the application. The submission of a copy of the escrow agreement or letter of credit will fulfill this requirement if the document contains such a description.
3. 3) A permit application fee of $100.00 (Section 4 of the Act).

4. 4) An audited statement of the facility's financial position in each of the three years prior to the application.

   1. A) If the facility has not previously existed, audited financial statements, including an equity statement, with descriptions of the facility's start-up capital and financing are required.
   2. B) Financial statements of the provider shall be prepared in accordance with generally accepted accounting principles and reported upon by certified public accountants with generally accepted auditing standards.

5. 5) The identity of the licensed or facilities at which licensed care will be provided to those residents in need of such care, as provided for in life care contract.

   1. A) Newly constructed facilities may make licensed long term care beds available to non-residents only with the approval of the Department. Approval will be based upon whether the facility will be providing sufficient licensed beds to accomodate its residents without having to transfer or discharge any resident or non-resident. Facilities seeking such approval shall include with the application a written explanation as to how the above will be accomplished. This explanation shall include at a minimum, the number and type of licensed beds at the facility, the maximum number of beds that will be used for non-residents, a description of any plans to phase out the number of beds to be used for non-residents, and projections of the number and types of licensed beds that will be needed for residents, along with the basis for those projections. Facilities which received a "continuum of care variance" from the Illinois Health Facilities Planning Board under 77 Ill. Adm. Code 1110.1730(c)(3) will not receive approval to admit non-residents to long-term care beds.
   2. B) If the life care facility contains no licensed long-term care beds, a written explanation of plans to meet the eventual needs of those residents who require contractually entitled levels of care, beyond maintenance services in living units, must be provided to the Department at the time of application. "Living units", and "Maintenance Services" are defined in Section 396.10 of the Life Care Facilities Contract Code.