Provider Forms

Note that IDPH forms may require use of Internet Explorer to open

Form
Description
Document
IDPH License Reinstatement
For requesting a license to become reinstated
IDPH Fee Schedule
This is the fee schedule for new and renewing license
IDPH License Reactivation
For providers whose license is currently inactive and is requesting it to become active again
IDPH License Extension Request
For providers requesting a license extension
IDPH Inactive License Form
For providers who want to make their license inactive
IDPH Fee Waiver
This is for providers who serve only on a volunteer service or is part of the Illinois National Guard.
IDPH Military License Form
This form is for providers who are former/current military to apply for an IDPH EMS License