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Medical Providers
Medical Programs Forms
Medical Programs Alphabetical Listing of Forms
Medical Programs Alphabetical Listing of Forms
Abortion Payment Application HFS 2390 (pdf)
Abortion Payment Application HFS 2390S (pdf) (Spanish)
Additional Financial Information for Long Term Care Applicants HFS 3654 (pdf)
Additional Financial Information for Long Term Care Applicants HFS 3654S (pdf)
Adjustment Form (Hospital) HFS 2249 (pdf)
Advance Practice Nurse (APN) Certification and Collaborative Agreement Form HFS 3411C (pdf)
Agreement for Participation HFS 1413 (pdf)
All Kids Application KC 2378KCC (English)
All Kids Application KC 2378KCCS (Spanish)
Application for Payment of Medicare Premiums, Deductibles and Coinsurance HFS 2378M (pdf)
Application for Payment of Medicare Premiums, Deductibles and Coinsurance Spanish HFS 2378MS (pdf)
Augmentative Communication Systems Assessment Review Checklist HFS 3640 (pdf)
Augmentative Communication Systems Client Assessment Report HFS 3461 (pdf)
Certification and Attestation for Primary Care Rate Increase HFS 2352 (pdf)
Citizenship Documents and Your Medical Benefits HFS 3859D (pdf)
Citizenship Documents and Your Medical Benefits HFS 3859DS(Spanish) (pdf)
Client/applicant Discrimination Claim HFS 185 (pdf)
Compliance Report for Skilled Nursing HFS 2022 (pdf)
C-PAP/BiPAP Renewal Questionnaire HFS 3701F (pdf)
Forms Request (Springfield) HFS 1517 (pdf) Online Form Request
Health Agency Invoice HFS 2212 (pdf) (OCR)
Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MB (html)
Health Insurance Claim Form HFS 2360 (pdf) (OCR)
Hospital Bed Questionnaire HFS 3905 (pdf)
Hospital, Professional School or Group Practice as Alternate Payee For HFS 2307 (pdf)
Hysterectomy Information HFS 1977 (pdf)
Hysterectomy Information HFS 1977S (pdf) (Spanish)
Illinois Department on Aging (IDoA) Notification HFS 2538B (pdf)
Interagency Certification of Screening Results HFS 2536 (pdf)
Laboratory / Portable X-Ray Invoice HFS 2211 (pdf) (OCR)
Late Filing Affidavit HFS 3773 (pdf)
Limited Power of Attorney HFS 2316 (pdf)
Long Term Care (SNF/ICF) Provider Monthly Assessment Report HFS 1446 (pdf)
Long Term Care Bed Reserve/Temporary Absence Form HFS 2234 (pdf)
Long Term Care Facility Notification HFS 1156 (pdf)
Long Term Care Facility Third Party Liability (TPL) Payment Transmittal HFS 3641 (pdf)
Long Term Care Provider Agreement ICF/DD (Provider Type 29) HFS 1432A (pdf)
Long Term Care Provider Agreement Nursing Facilities (Provider Type 33) HFS 1432 (pdf)
Long Term Care Provider Agreement State-Operated Facility (Provider Type 34) HFS 1433 (pdf)
Long Term Care Provider Agreement SLF (Provider Type 28) HFS 1432B (pdf)
MCH Primary Care Provider Agreement HFS 3411A (pdf)
Medical Benefits Application Mail-in HFS 2378H (pdf)
Medical Benefits Application Mail-in HFS 2378HS (pdf) (Spanish)
Medical Equipment / Medical Supplies HFS 2210 (pdf) (OCR)
Medicare Crossover Invoice HFS 3797 (pdf) (OCR)
Motorized Wheelchair Evaluation Form HFS 3867 (pdf)
Non-emergency Transportation Fingerprint Form HFS 3819 (pdf)
Notice of DHS Community – Based Services HFS 2653 (pdf)
Nursing Assistant Training and Competency Evaluation Reimbursement Request HFS 2310 (pdf)
Nursing Facility Traumatic Brain Injury (TBI) Notification HFS 1435 (pdf)
Nursing Facility Ventilator Notification HFS 106 (pdf)
Optical Prescription Order HFS 2803 (pdf) (OCR)
Payment Review Request Form (LTC) HFS 3725 (pdf)
Payment to Corporate Owner/Assurances HFS 2314 (pdf)
Power Mobility Devices (Pmds) And Custom Manual Wheelchairs HFS 3701K (pdf)
Instruction for HFS 3701K (pdf)
Power of Attorney HFS 2306 (pdf)
Preconception Screening Checklist HFS 27(fillable pdf) or (printer friendly version)
Primary Care Provider Authorization (Non-Emergency Services Only) HFS 1662 (pdf)
Prior Approval Request HFS 1409 (pdf)
Prior Approval Request Instructions HFS 1409i (pdf)
Progress Report For Specialized Wound Therapy (pdf) HFS 3785A (pdf)
Provider Enrollment Application HFS 2243 (pdf)
Instruction for HFS 2243 (pdf)
Provider Invoice HFS 1443 (pdf) (OCR)
Questionnaire for Specialized Wound Therapy (pdf) HFS 3785 (pdf)
Questionnaire for TENS Unit HFS 3701E (pdf)
Refill Too Soon Prior Approval Worksheet HFS 3082A (pdf)
Remittance Advice HFS 194-M-2 (pdf) (OCR)
Report on Resident of Private Long Term Care Faciltiy HFS 26 (pdf)
Request for Drug Prior Approval Form HFS 3082 (pdf)
Request for Extended Sass Services Form HFS 3833 (pdf)
Request For Inappropriate Level Of Care Payment HFS 3127 (pdf)
Screening Verification Form HFS 3864 (pdf)
Seating/Mobility Evaluation HFS 3701H (pdf)
Instruction for HFS 3701H (pdf)
SLF Program Notice of Appeal HFS 3734 (pdf)
SLF Program Notice of Involuntary Discharge HFS 3137 (pdf)
Special Decubitus Mattress Questionnaire HFS 3701G (pdf)
Statement of Good Faith Effort HFS 3859B (pdf)
Statement of Good Faith Effort HFS 3859BS (Spanish) (pdf)
Statement of Identity HFS 3859 (pdf)
Statement of Identity HFS 3859S (Spanish) (pdf)
Sterilization Consent Form HFS 2189 (pdf)
Sterilization Consent Form HFS 2189S (pdf) (Spanish)
Transportation Agreement for Participation HFS 1413T (pdf)
Transportation Invoice HFS 2209 (pdf) (OCR)
UB-04 Example Only - Not Supplied by HFS CMS 1450 (pdf) (OCR)
Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown HFS 2538C (pdf)
Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown HFS 2538CS (pdf) (Spanish)
Voter Registration Application SBER19 (pdf)
Voter Registration Application SBER19 (Spanish) (pdf)
Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413A (pdf)
Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413AS (pdf) (Spanish)
Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413B(pdf)
Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413BS (pdf) (Spanish)
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