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