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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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