<>/Border[0 0 0]/H/N/Rect[48.5 279.61099 203.00702 269.61099]/Subtype/Link/Type/Annot/URI(http://dph.illinois.gov/topics-services/emergency-preparedness-response/ems/res_sysListing)>> Ownership for an Existing Health Care Facility, Health Facilities Planning Board -
Springfield: 217-52 4-DoIT (217-524-3648) Chicago: 312-81 4-DoIT (312-814-3648) Technical Support Week Days (8A-5P, Monday-Friday) Contact the IDPH Helpdesk at 866-220-5247 or via email at DPH.Helpdesk@illinois.gov for Portal access and web-based application support. 38 0 obj "ChpEObbG]!>E5o(fV+. %%EOF It costs nothing to change your name unless you want a duplicate license mailed out. 0000043771 00000 n
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Trauma Nurse Specialist (TNS) Application Instruction Guide
Intended Father Form - PDF
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Remember, you will not be allowed to function as an EMS provider until you have in your possession the new EMT-B license. PDF
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Plumbing Contractor Surety Bond Forms
IDPH EMS LICENSING BROCHURE for INDEPENDENTS For more information regarding relicensure in the Silver Cross EMS System, please contact Marilyn MacBlane, EMS Operations Coordinator at 815-300-2900 for assistance. Application for Manufactured Home Manufacturer License
Instrument Dispenser License Application Form - PDF
Matrix 4A - UL Assembly Ratings - Fillable PDF*
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Then change your surname . Independent EMS License Renewal Request Form - PDF
Trauma Nurse Specialist (TNS) Examination Roster - PDF (Word), Eye Examination Report 2009 - PDF
Facility Information Change Form - Fillable PDF*, Rural Health Medicare Certification - PDF
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Create an account Account Id Password visibility_off License Number
Which name do I submit for licensure? Biological Father Affidavit
Freestanding Emergency Center (FEC) Initial Licensure Application - Fillable PDF
Hospital Medicare Certification - PDF
Dialysis Medicare Certification, End Stage Renal Dialysis Medicare Certification, Freestanding Emergency Center (FEC) Initial Licensure Application, Freestanding Emergency Center (FEC) Renewal Licensure Application, Project Submission Form for Freestanding Emergency Center, Health
Outpatient Rehab Facility Medicare Certification - PDF
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Foreign Nurse Application - PDF
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This site has been designed to be a resource for learning about Iowa's EMS system and to provide necessary information regarding EMS provider certification and renewal, andservice program authorization. Pediatric Lead Poisoning High-Risk ZIP Code Areas - En Espaol - PDF
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2023.2.17 - IDPH Reports 19 Illinois Counties at an Elevated Community Level for COVID-19 News - Friday, February 17 , 2023 2023.2.10 - IDPH Reports 15 Illinois Counties at an Elevated Community Level for COVID-19 Read their report below. Renewal Notice - PDF
name change information: *Must include stamped or certified document (or photocopy of a stamped or certified) of one of the following: marriage certificate divorce decree court order naturalization document 0000028220 00000 n
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Project Submission Form for Freestanding Emergency Center - Fillable PDF
Special Flood Hazard Area Location Request Form - PDF, Certificate of Child Health Examination Form - PDF, Comprehensive
PDF, Birth Record Files, Application for Search of - PDF
Checklist, Lead Public Information Disclosure
Initial Licensure IDPH Administrative Code on EMT Licensure 2020 Transition to National Registry Testing (NREMT) IDPH Memo - July 2019 0000003950 00000 n
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Water Well Construction Report - Fillable PDF*
IDPH EMS Licensing For more information and to access the IDPH EMS licensing forms. Please contact the Division of EMS and Highway Safety at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. - PDF
from The Hill: The Supreme Court upholds administrative agency actions alleged to be arbitrary 92 percent of the time. Welcome to the Illinois Department of Public Health, Division of EMS and Highway Safetys online licensing site. Gestational Surrogate Form - PDF
Application (General Use) - PDF -
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Lead Risk Assessment Questionnaire, Medical Childhood - Excel (Longitudinal record for physician office use)
How to Search for Discipline and Public Actions Select the specific licensing board from the list to the left Health Agency - Hospice Add or Remove Geographic Service Areas - PDF
A person currently licensed as an EMT, Intermediate, or Paramedic may only use their EMS license in pc3te^C~3WdZfl56*
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To pay your license fee with the Department of Public Health, which you must do before you can receive a license, click the link for Online Services. Application for Youth Camp Construction Permit - PDF
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Scholarship Program Application - PDF, School Physical -- Certificate of Child Health Examination Form, Integrated Pest Management Forms (See Integrated Pest Management)
Birth Record Files of a Deceased Individual, Application for Search of - PDF
Our mission is to protect and promote the lives of Illinois consumers. 0000026085 00000 n
Health Care Facilities Complaint Form - Fillable PDF* (PDF without form fields), Licensed Day Care Centers Form - Fillable PDF*
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Dental Examination Waiver Form - PDFEn Espaol - PDF, Discharge and Opportunity for Hearing for Nursing Home Residents, Notice of Involuntary Transfer or, Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents Form - En Espaol - Fillable PDF*, Alternate Rural Staffing and Response Authorization Request - Fillable PDF
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EMS Service Programs shall submit a completed application and documentation that they meet or exceed the minimum requirements of Iowa administrative code 641-132. Under the menu, go to Desktops or Apps, click on Details next to your choice and then select Add to Favorites. EMS - Service Information. Request for Manufactured Home Installation Seals and Certificates
Freestanding Emergency Center (FEC) Renewal Licensure Application - Fillable PDF
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endobj About Us Back; Stakeholders Relations; Services . Out of State CNA Application - PDF
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PROVIDING LIFE SAVINGS SOLUTIONS SINCE 2009. For IDPH Forms and Documents, please click on this link to take you to the IDPH website. The RH will then submit the completed paperwork to IDPH and notify your employer of the change in your level of licensure. Please contact the Division at 217-785-2080 or at DPH.EMTLIC@illinois.gov with questions or for more information. endobj 0000040208 00000 n
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Social Worker/Worker Assistant Qualifications Review - Attachment D, Agency Manager Qualification Review - Attachment E, Home Health Agency Management Status Form, Home
Facility Information Change Form - Fillable PDF*, Application for Registration of Continuing Education - PDF
Health Agency Administrative Staff Changes, Home Health Agency Administrator Qualifications Review - Attachment A, Home
Irrigation Contractor Application Child Support Certification - PDFPlumbing Contractor Registration Online Renewals
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