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Click ‘Get Form’ to open the psa illinois document in the editor.
Begin with Part A, where you will check all applicable sub-areas your agency intends to serve. Ensure you mark each relevant area clearly.
In Part B, provide your agency's legal name and administrative office address. Fill in the contact person's details, including their title and email.
Complete Part C by answering Yes or No for each question regarding compliance with Community Care Program rules. Be thorough to avoid any issues.
For transportation details in Part D, specify how transportation will be provided to participants as required by the Plan of Care.
In Part E, complete the Electronic Visit Verification (EVV) Certification section by detailing the EVV system used and providing contact information for verification.
Finally, sign and date the Applicant Signature Page in Part G, ensuring all information is accurate before submission.

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