Medical Forms Numeric Listing

HFS 458 LTC Notice of Decision on Application for Medical Assistance MANG LTC/SLF (pdf)
HFS 458 LTC Notice of Decision on Application for Medical Assistance MANG LTC/SLF (Spanish) (pdf)
CMS 1450 UB-04 Example Only - Not Supplied by HFS (OCR) (pdf)
CMS 1450 UB-04 Example Only - Not Supplied by HFS (OCR) (pdf)
HFS 26 Report on Resident of Private Long Term Care Facility (pdf)
HFS 27 Preconception Screening Checklist (pdf)
HFS 106 Nursing Facility Ventilator Notification (pdf)
HFS 185 Client/applicant Discrimination Claim (pdf)
HFS 650 Standardized Illinois Early Intervention Referral Form (pdf)
HFS 650S Standardized Illinois Early Intervention Referral Form (Spanish) (pdf)
HFS 652 Illinois Early Intervention Program Referral Fax Back Form (pdf)
HFS 724 Screening, Assessment and Evaluation Tool Approval Request Form (pdf)
HFS 1156 Long Term Care Facility Notification (pdf)
HFS 1305 Questionnaire For Human Donor Milk (pdf)
HFS 1313 DME Form for Medical Food (pdf)
HFS 1329 Hospital Long Term Care Days Request (pdf)
HFS 1409 Prior Approval Request (pdf)
HFS 1409i Prior Approval Request Instructions for HFS 1409 (pdf)
HFS 1409X Pharmacy Prior Authorization Request (pdf)
HFS 1413 Agreement for Participation in the Illinois Medical Assistance Program (pdf)
HFS 1413S Agreement for Participation in the Illinois Medical Assistance Program (Spanish) (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 (Spanish) (pdf)
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 (Spanish) (pdf)
HFS 1432 Long Term Care Provider Agreement Nursing Facilities and ICF/IID (Provider Types 33 and 29) (pdf)
HFS 1432B Long Term Care Provider Agreement Supportive Living Facility (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 Example Only (OCR) (pdf)
HFS 1446 Long Term Care (SNF/ICF) Provider Monthly Assessment Report (pdf)
HFS 1517 Provider Forms Request (Springfield) (pdf) or Online Form Request
HFS 1592 Notification to HFS of Illinois Medicaid Hospice Benefit Election (pdf)
HFS 1593 Notification to HFS of Illinois Medicaid Hospice Benefit - Continuing Benefit Period and Recertification of Terminal Illness (pdf)
HFS 1594 Notification to HFS of Patient Discharge from Hospice Care (pdf)
HFS 1624 Override Request Form (pdf)
HFS 1624A UB-04 Override Request Form (pdf)
HFS 1662 Primary Care Provider Authorization (Non-Emergency Services Only) (pdf)
HFS 1706G Integrated Eligibility System (IES) Access Request (pdf)
HFS 1977 Acknowledgement of Receipt of Hysterectomy Information (pdf)
HFS 1977S Acknowledgement of Receipt of Hysterectomy Information (Spanish) (pdf)
HFS 2022 Compliance Report for Skilled Nursing (pdf)
HFS 2189 Sterilization Consent Form (pdf)
HFS 2189S Sterilization Consent Form (Spanish) (pdf)
HFS 2209 Transportation Invoice Example Only (OCR) (pdf)
HFS 2210 Medical Equipment / Supplies Invoice Example Only (OCR) (pdf)
HFS 2211 Laboratory / Portable X-Ray Invoice Example Only (OCR) (pdf)
HFS 2212 Health Agency Invoice Example Only (OCR) (pdf)
HFS 2234 Long Term Care Bed Reserve/Temporary Absence Form (pdf)
HFS 2243 Provider Enrollment Application in the Medical Assistance Program (pdf)
HFS 2243 Provider Enrollment Application Instructions for the HFS 2243 (pdf)
HFS 2249 Adjustment Form (Hospital) (pdf)
HFS 2270 Physician Certification Statement (PCS) for Ambulance Transport (pdf)
HFS 2271 Certification of Transportation Services form (pdf)
HFS 2292 Adjustment Form (NIPS) (pdf)
HFS 2305 Wound Measurement Assessment Form (pdf)
HFS 2305A Air Fluidized Bed Questionnaire (pdf)
HFS 2305B Questionnaire for Airway Clearance Device (pdf)
HFS 2305C Questionnaire for Continued Rental of Airway Clearance Device (pdf)
HFS 2305D Certificate of Medical Necessity for Continuation of External Insulin Infusion Pump Rental(pdf)
HFS 2305E Questionnaire and Order for Cranial Remolding Orthosis or Cranial Cervical Orthosis Congenital Torticollis Type (pdf)
HFS 2305F Certificate of Medical Necessity for External Insulin Infusion Pump (pdf)
HFS 2305G Questionnaire for Home Apnea Monitor (pdf)
HFS 2305H Questionnaire for Home Phototherapy (pdf)
HFS 2305I Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES) (pdf)
HFS 2305J Questionnaire for Prosthesis (pdf)
HFS 2305K Compression/Burn Garments Questionnaire (pdf)
HFS 2305M Knee Brace Questionnaire (pdf)
HFS 2305N Questionnaire for Orthosis (pdf)
HFS 2306 Power of Attorney (pdf)
HFS 2307 Hospital, Professional School or Group Practice as Alternate Payee (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 Example Only (OCR) (pdf)
HFS 2378ABE Application for Health Coverage and Help Paying Costs (pdf)
HFS 2378ABES Application for Health Coverage and Help Paying Costs (Spanish) (pdf)
HFS 2378H Mail-in Application for Medical Benefits (pdf)
HFS 2378HS Mail-in Application for Medical Benefits (Spanish) (pdf)
HFS 2378M Application for Payment of Medicare Premiums, Deductibles and Coinsurance (pdf)
HFS 2378MB Health Benefits for Workers with Disabilities (HBWD) Application (html) (pdf)
HFS 2378MBS Health Benefits for Workers with Disabilities (HBWD) Application (Spanish) (pdf)
HFS 2378MS Application for Payment of Medicare Premiums, Deductibles and Coinsurance (Spanish) (pdf)
HFS 2378WA Application for Hardship Waiver of a Penalty Period (pdf)
HFS 2378WAS Application for Hardship Waiver of a Penalty Waiver (Spanish) (pdf)
HFS 2379WA Statement of Hardship - Request for Waiver of Penalty Period (pdf)
HFS 2379WAS Statement of Hardship - Request for Waiver of Penalty Period (Spanish) (pdf)
HFS 2536 Interagency Certification of Screening Results (pdf)
HFS 2538B llinois Department on Aging (IDoA) Notification (pdf)
HFS 2538BS Illinois Department on Aging (IDoA) Notification (Spanish) (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 (Spanish) (pdf)
HFS 2653 Notice of DHS Community – Based Services (pdf)
HFS 2803 Optical Prescription Order (OCR) (pdf)
HFS 3082 Request for Drug Prior Approval Form (pdf)
HFS 3082A Refill Too Soon Prior Approval Worksheet (pdf)
HFS 3120 Medicaid Payment of Medicare Cost Sharing Expenses (pdf)
HFS 3120S Medicaid Payment of Medicare Cost Sharing Expenses (pdf)
HFS 3127 Request For Inappropriate Level Of Care Payment (pdf)
HFS 3365 Handicapping Labio-Lingual Deviation Index (HLD) Score Sheet (pdf)
HFS 3411A MCH Primary Care Provider Agreement (pdf)
HFS 3411C Advance Practice Nurse (APN) Certification and Collaborative Agreement Form (pdf)
HFS 3461 Long Term Care Facility Third Party Liability (TPL) Payment Transmittal (pdf)
HFS 3640 Augmentative Communication Systems Assessment Review Checklist (pdf)
HFS 3641 Augmentative Communication Systems Client Assessment Report (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)
HFS 3701I Appendix E-3b Binaural Hearing Aid Questionnaire (pdf)
HFS 3701K Power Mobility Devices and Custom Manual Wheelchair Request Instructions for HFS 3701H (pdf)
HFS 3701L Standard Manual Wheelchair Questionnaire (pdf)
HFS 3701M Questionnaire for Food Thickeners (pdf)
HFS 3701N Questionnaire for Enteral Nutrition (pdf)
HFS 3701T Therapy Prior Approval Request Form (pdf)
HFS 3701TI Therapy Prior Approval Request Form Instructions for HFS 3701T(pdf)
HFS 3725 Payment Review Request Form (LTC) (pdf)
HFS 3731 Supportive Living Program Notice of Involuntary Discharge (pdf)
HFS 3732 Involuntary Discharge Notice of Appeal and Request for Hearing (pdf)
HFS 3734 Supportive Living Program Notice of Appeal (pdf)
HFS 3757 Medicare Savings for Qualified Beneficiaries Brochure (pdf)
HFS 3757S Medicare Savings for Qualified Beneficiaries Brochure (Spanish) (pdf)
HFS 3773 Late Filing Affidavit (pdf)
HFS 3785 Questionnaire for Negative Pressure Wound Therapy (pdf)
HFS 3785A Progress Report for Negative Pressure Wound Therapy (pdf)
HFS 3797 Medicare Crossover Invoice Example Only (OCR) (pdf)
HFS 3819 Non-emergency Transportation Fingerprint Form (pdf)
HFS 3825 Medicar/Service Car/Taxicab Uniform Trip Ticket (pdf)
HFS 3830 Dispatch Log (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)
IL 444-2378B Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) (pdf)
IL 444-2378BS Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) (pdf)
IL 444-2636 Record of Birth (pdf)
IL 444-2998 - Approved Representative Consent Form (pdf)
IL 444-2998S - Approved Representative Consent Form (Spanish) (pdf)
SBE R-19 Voter Registration Application (pdf)
SBE R-19 Voter Registration Application (Spanish) (pdf)

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