State of Illinois
Illinois Department of Public Health
ASSISTED LIVING AND SHARED HOUSING
INVOLUNTARY TERMINATION of RESIDENCY FORM
Name of Resident ____________________________________ Date of Notice ________________
Name of Establishment _____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Address City/ZIP Code
Contact Name
Reason for Residency Termination ____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Proposed Date of Termination ______________________________________________________
The above resident has the right to appeal residency termination. A 30-day prior written
notice must be provided to the resident, residentâs representative, or both, and to the long-term
care ombudsman. The establishment must notify the Illinois Department of Public Health
when it initiates the termination process. All forms given to the resident can be faxed to the
Illinois Department of Public Health (IDPH) at 217-557-2432.
THE RESIDENT MAY INITIATE AN APPEAL BY:
a) calling IDPH, Division of Assisted Living at 217-782-2448
OR
b) sending the signed Appeal Hearing Request form to IDPH (see Appeal Hearing Request form)
The resident has the right to continue to reside in the establishment until a decision is
rendered.
The person at the establishment who will assist with relocation is:
Name of Person __________________________________________________________________
__________________________________________________________________________________
Address
City/ZIP Code Telephone Number
IOCI 15-577
Telephone
Email
1
State of Illinois
Illinois Department of Public Health
State of Illinois
Illinois Department of Public Health
ASSISTED LIVING AND SHARED HOUSING
FACILITY REPRESENTATIVE DISCLOSURE
Pursuant to Section 100.4 (a) of the Department of Public Health's Rules of Practice and Procedure in
Administrative Hearings:
âA corporation, a limited liability company, partnership, association or certified local health
department shall appear and be represented only by an attorney authorized to practice law in
the State of Illinois. A shareholder, corporate officer, employee, or member of the board of
directors may not appear or represent a corporation or association unless that individual is
authorized to practice law in the State of Illinois.â
The facility is required to be represented by counsel. Please identify the attorney who will represent the
facility at all hearings:
Name of Facility to be represented: _________________________________
Representative name: ____________________________________________
Firm name: ____________________________________________________
Address 1: _____________________________________________________
Address 2: _____________________________________________________
State: ________ Zip: __________
City: _______________________
Phone number: _____________________
Fax: ______________________
Email: _________________________________________________________
(used for hearings with Administrative Law Judges)
Please forward the completed forms to IDPH
by one of the following methods.
US mail:
Illinois Department of Public Health
Division of Assisted Living
525 West Jefferson Street, 5th Floor
Springfield, IL 62761
Fax:
217-557-2432
Email:
2
State of Illinois
Illinois Department of Public Health
IOCI 15-577
ASSISTED LIVING AND SHARED HOUSING
HEARING REQUEST FORM
Name of Resident Requesting Appeal Hearing____________________________________________
___________________________________________________________________________________
Address
City/ZIP Code
Email
Address
City/ZIP Code
Telephone Number
I request a hearing to be conducted by the Illinois Department of Public Health to contest the notice
of residency termination or discharge received by ______________ on _____________ 20 ___.
Signature of Person Requesting a Hearing ______________________________________________
Relationship to Resident (if applicable) __________________________Date_______________
Resident or Resident's Representative Printed Name _____________________________________
________________________________________________________________________________
________________________________________________________________________________
INSTRUCTIONS: If you wish to contest the proposed residency termination or discharge, please
complete this form. Use the postage-paid, pre-addressed envelope provided to you to mail this form
and the Involuntary Termination of Residency form to:
Illinois Department of Public Health
Division of Assisted Living,
525 West Jefferson Street, 5th Floor
Springfield, Illinois 62761
or fax: 217-557-2432
Please submit completed forms within 10 DAYS after receiving the Involuntary
Termination of Residency form from the facility.
___________________________________________________________________________________
Telephone Number
Name of Facility ______________________________________________________________
___________________________________________________________________________________
(Resident or Resident's Representative)
City/ZIP Code
Telephone Number
3
