Medical Forms Alphabetical Listing

Acknowledgment of Receipt of Hysterectomy Information HFS 1977 (pdf)
Acknowledgment of Receipt of Hysterectomy Information HFS 1977S (Spanish) (pdf)
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)
Adjustment Form (NIPS) HFS 2292 (pdf)
Advance Practice Nurse (APN) Certification and Collaborative Agreement Form HFS 3411C (pdf)
Agreement for Participation in the Illinois Medical Assistance Program HFS 1413 (pdf)
Agreement for Participation in the Illinois Medical Assistance Program HFS 1413S (Spanish) (pdf)
Air Fluidized Bed Questionnaire HFS 2305A (pdf)
Appendix E-3b Binaural Hearing Aid Questionnaire HFS 3701I (pdf)
Application for Hardship Waiver of a Penalty Period HFS 2378WA (pdf)
Application for Hardship Waiver of a Penalty Period HFS2378WAS (Spanish) (pdf)
Application for Health Coverage and Help Paying Costs HFS 2378ABE (pdf)
Application for Health Coverage and Help Paying Costs HFS 2378ABES (pdf)
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)
Approved Representative Consent Form IL444-2998 (pdf)
Approved Representative Consent Form IL444-2998S (Spanish) (pdf)
Augmentative Communication Systems Assessment Review Checklist HFS 3640 (pdf)
Augmentative Communication Systems Client Assessment Report HFS 3641 (pdf)
Certificate of Medical Necessity for Continuation of External Insulin Infusion Pump Rental HFS 2305D (pdf)
Certificate of Medical Necessity for External Insulin Infusion Pump HFS 2305F (pdf)
Certificate of Transportation Services HFS 2271 (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)
Compression/Burn Garments Questionnaire HFS 2305K (pdf)
C-PAP/BiPAP Renewal Questionnaire HFS 3701F (pdf)
Dispatch Log HFS 3830 (pdf)
DME Form for Medical Foods (pdf)
Health Agency Invoice Example Only HFS 2212 (OCR) (pdf)
Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MB (html) (pdf)
Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MBS (Spanish) (pdf)
Health Insurance Claim Form Example Only HFS 2360 (OCR) (pdf)
Hospital Bed Questionnaire HFS 3905 (pdf)
Hospital Long Term Care Days Request HFS 1329 (pdf)
Hospital, Professional School or Group Practice as Alternate Payee HFS 2307 (pdf)
Illinois Department on Aging (IDoA) Notification HFS 2538B (pdf)
Illinois Department on Aging (IDoA) Notification HFS 2538BS (Spanish) (pdf)
Illinois Early Intervention Program Referral Fax Back Form HFS 652 (pdf)
Integrated Eligibility System (IES) Access Request HFS 1706G (pdf)
Interagency Certification of Screening Results HFS 2536 (pdf)
Involuntary Discharge Notice of Appeal and Request for Hearing HFS 3732 (pdf)
Knee Brace Questionnaire HFS 2305M (pdf)
Laboratory / Portable X-Ray Invoice Example Only 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 3461 (pdf)
Long Term Care Provider Agreement Nursing Facilities and ICF/IID (Provider Types 33 and 29) HFS 1432 (pdf)
Long Term Care Provider Agreement State-Operated Facility (Provider Type 34) HFS 1433 (pdf)
Long Term Care Provider Agreement Supportive Living Facility (Provider Type 28) HFS 1432B (pdf)
Mail-in Application for Medical Benefits HFS 2378H (pdf)
Mail-in Application for Medical Benefits HFS 2378HS (Spanish) (pdf)
MCH Primary Care Provider Agreement HFS 3411A (pdf)
Medicaid Payment of Medicare Cost Sharing Expenses HFS 3120 (pdf)
Medicaid Payment of Medicare Cost Sharing Expenses HFS 3120S (Spanish) (pdf)
Medical Equipment / Supplies Invoice Example Only HFS 2210 (OCR) (pdf)
Medicar/Service Car/Taxicab Uniform Trip Ticket HFS 3825 (pdf)
Medicare Crossover Invoice Example Only HFS 3797 (OCR) (pdf)
Medicare Savings for Qualified Beneficiaries Brochure HFS 3757 (pdf)
Medicare Savings for Qualified Beneficiaries Brochure (Spanish) HFS 3757S (Spanish) (pdf)
Motorized Wheelchair Evaluation Form HFS 3867 (pdf)
Non-emergency Transportation Fingerprint Form HFS 3819 (pdf)
Notice of DHS Community – Based Services HFS 2653 (pdf)
Notification to HFS of Illinois Medicaid Hospice Benefit Election HFS 1592 (pdf)
Notification to HFS of Illinois Medicaid Hospice Benefit - Continuing Benefit Period and Recertification of Terminal Illness HFS 1593 (pdf)
Notification to HFS of Patient Discharge from Hospice Care HFS 1594 (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 (OCR) (pdf)
Override Request Form HFS 1624 (pdf)
Payment Review Request Form (LTC) HFS 3725 (pdf)
Payment to Corporate Owner/Assurances HFS 2314 (pdf)
Pharmacy Prior Authorization Request HFS 1409X (pdf)
Physician Certification Statement HFS 2270 (pdf)
Power Mobility Devices and Custom Manual Wheelchair Request Instructions for HFS 3701K (pdf)
Power of Attorney HFS 2306 (pdf)
Preconception Screening Checklist HFS 27(pdf)
Primary Care Provider Authorization (Non-Emergency Services Only) HFS 1662 (pdf)
Prior Approval Request HFS 1409 (pdf)
Prior Approval Request Instructions HFS 1409 (pdf)
Prior Authorization for Adaptive Behavioral Support Services (pdf)
Progress Report for Negative Pressure Wound Therapy HFS 3785A (pdf)
Provider Enrollment Application in the Illinois Medical Assistance Program HFS 2243 (pdf)
Provider Enrollment Application Instructions for HFS 2243 (pdf)
Provider Forms Request (Springfield) HFS 1517 (pdf) or Online Form Request
Provider Invoice Example Only HFS 1443 (OCR) (pdf)
Questionnaire and Order for Cranial Remolding Orthosis or Cranial Cervical Orthosis Congenital Torticollis Type HFS 2305E (pdf)
Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES) HFS 2305I (pdf)
Questionnaire for Airway Clearance Device HFS 2305B (pdf)
Questionnaire for Continued Rental of Airway Clearance Device HFS 2305C (pdf)
Questionnaire for Enteral Nutrition HFS 3701N (pdf)
Questionnaire for Food Thickeners HFS 3701M (pdf)
Questionnaire for Home Apnea Monitor HFS 2305G (pdf)
Questionnaire for Home Phototherapy HFS 2305H (pdf)
Questionnaire for Negative Pressure Wound Therapy HFS 3785 (pdf)
Questionnaire for Orthosis HFS 2305N (pdf)
Questionnaire for Prosthesis HFS 2305J (pdf)
Questionnaire for TENS Unit HFS 3701E (pdf)
Record of Birth IL 444-2636 (pdf)
Refill Too Soon Prior Approval Worksheet HFS 3082A (pdf)
Report on Resident of Private Long Term Care Faciltiy HFS 26 (pdf)
Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) IL 444-2378B (pdf)
Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) IL 444-2378BS (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)
Screening, Assessment and Evaluation Tool Approval Request Form HFS 724 (pdf)
Seating/Mobility Evaluation HFS 3701H (pdf)
Special Decubitus Mattress Questionnaire HFS 3701G (pdf)
Standard Manual Wheelchair Questionnaire HFS 3701L (pdf)
Standardized Illinois Early Intervention Referral Form HFS 650 (pdf)
Standardized Illinois Early Intervention Referral Form HFS 650S (Spanish) (pdf)
Statement of Good Faith Effort HFS 3859B (pdf)
Statement of Good Faith Effort HFS 3859BS (Spanish) (pdf)
Statement of Hardship - Request for Waiver of Penalty Period HFS 2379WA (pdf)
Statement of Hardship - Request for Waiver of Penalty Period HFS 2379WAS (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 (Spanish) (pdf)
Supportive Living Facilities Program Notice of Appeal HFS 3734 (pdf)
Supportive Living Facilities Program Notice of Involuntary Discharge HFS 3131 (pdf)
Therapy Prior Approval Request Form HFS 3701T (pdf)
Therapy Prior Approval Request Form Instructions for HFS 3701T (pdf)
Transportation Invoice Example Only HFS 2209 (pdf) (OCR)
UB-04 Example Only - Not Supplied by HFS CMS 1450 (pdf) (OCR)
UB-40 Override Request Form HFS 1624A (pdf)
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 (Spanish) (pdf)
Voter Registration Application SBE R-19 (pdf)
Voter Registration Application SBE R-19 (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 (Spanish) (pdf)
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 (Spanish) (pdf)
Wound Measurement Assessment Form HFS 2305 (pdf)

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Medical Forms Alphabetical Listing

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