SUPR Licensing and Certification Forms

Substance Use Disorder Services Application (pdf)All original completed forms should be mailed to:

• Illinois Department of Human Services
• Division of Substance Use Prevention and Recovery
• Licensing and Certification
• 401 South Clinton Street, Second Floor
• Chicago, Illinois 60607-3800
   

• For additional information about SUPR licensing and certification, please call (312) 814-3840.

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Initial Application for Substance Use Disorder Intervention/Treatment Provider or Apply for Medicaid Certification

• Substance Use Disorder Services Application Instructions and Guidelines

• (BEFORE beginning the application process, be sure to read the following two letters.) 

• Initial Application Cover Letter (pdf) - Initial application for Substance Use Disorder Intervention/Treatment License or Medicaid Certification. 

• The following rules govern substance abuse treatment and intervention services licensing (2060) and Medicaid certification (2090). Please read the applicable rule prior to completing the application.
  • Title 77, Illinois Administrative Code Rule 2060
  • Title 77, Illinois Administrative Code Rule 2090 
     

Important Notice for CITY OF CHICAGO providers:  A resolution from the Zoning Board of Appeals to obtain a Special Use Permit for a Transitional Shelter is REQUIRED to open a Residential Rehabilitation, Residential Extended Care facilities (Halfway House) and Recovery Homes in the City of Chicago.
 

• Substance Use Disorder Services Application Forms

  • Substance Use Disorder Services Application (pdf)
  • Substance Use Disorder Services Relocation Application (pdf)
  • Federally Qualified Health Center License Application Checklist (pdf)
  • Schedule A - Ownership Disclosure (pdf)
  • Schedule C - Statement of Compliance (pdf)
  • Schedule E - Medical Director, Physician or Physician Extenders (pdf)
  • Schedule L - Professional Staff (pdf)
  • W9 IRS form - Request for Taxpayer Identification & Certification (pdf)
  • W9 Instructions (pdf)

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Architect Life Safety Report Forms

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Off-site Exception Request Forms and Information

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If you continue to experience problems with accessing documents on this page, e-mail the SUPR Help Desk at DoIT.SUPRHelp@illinois.gov