Sign In
Menu
MY HEALTHCARE
MEDICAL PROVIDERS
CHILD SUPPORT SERVICES
INFO CENTER
ABOUT US
Anyone 6 months and older is eligible to receive the COVID-19 vaccine. Find your nearest vaccination location at
vaccines.gov
Stay informed with important
HFS Coronavirus 2019 (COVID-19) Updates
HFS Home
Illinois.gov
JB Pritzker,Governor
Theresa Eagleson,Director
It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again.
Site Navigation
MY HEALTHCARE
Medical Clients Home
Medical Programs
Change Your Medicaid Address
For Parents & Children
For Pregnant Women & Infants
For Seniors
For People with Disabilities
For Veterans
For Other Adults
For Immigrant Adults
Medicaid Recovery
MEDICAL PROVIDERS
HFS Application Agent
MPE/FPPE Providers
Medical Providers Home
Address Update Messaging Toolkit
Behavioral Health
Care Coordination
Hospitals and Institutional Providers
Non-Institutional Providers
Nursing Home Payment Update
Pharmacy
Electronic Visit Verification
Long Term Care
CHILD SUPPORT SERVICES
Parents
Employers
Attorneys
Hospitals
About
HFS OIG
INFO CENTER
Currently selected
Info Center Home
Agency Brochures
Agency Forms
Facts & Figures
For Media
Legal Center
Report Center
Diversity, Equity, and Inclusion
Healthcare Transformation
Success Stories
ABOUT US
Our Mission, Vision, and Values
About Us
Careers
Director Eagleson
Executive Staff
Phone Directory
Boards and Commissions
Office of Inspector General
HIPAA Privacy Forms Alphabetic Listing
HFS
>
Info Center
>
Legal Center
>
Health Insurance Portability and Accountability Act (HIPAA)
>
HIPAA Privacy Forms Alphabetic Listing
Page Content
Authorization to Disclose All Kids/FamilyCare Information HFS 3806K (pdf)
Authorization to Disclose All Kids/FamilyCare Information HFS 3806KS (pdf) (Spanish)
Authorization to Disclose Health Information HFS 3806D (pdf)
Authorization to Disclose Health Information HFS 3806DS
(pdf) (Spanish)
Complaint about Health Information Uses and Disclosures HFS 3806E (pdf)
Complaint about Health Information Uses and Disclosures HFS 3806ES (pdf) (Spanish)
Notice of Privacy Practice
HFS 3806 (pdf)
Notice of Privacy Practice HFS 3806S (pdf) (Spanish)
Personal Representative Designation HFS3806F (pdf)
Personal Representative Designation HFS 3806FS (pdf) (Spanish)
Request for Access to Health Information HFS 3806L (pdf)
Request for Access to Health Information HFS 3806LS (pdf) (Spanish)
Request for an Accounting of Disclosures of Health Information HFS 3806G (pdf)
Request for an Accounting of Disclosures of Health Information HFS 3806GS (pdf) (Spanish)
Request to Amend Health Information HFS 3806H (pdf)
Request to Amend Health Information HFS 3806HS (pdf) (Spanish)
Request to Contact Client at a Different Address HFS 3806I (pdf)
Request to Contact Client at a Different Address HFS 3806IS (pdf) (Spanish)
Request to Restrict Uses and Disclosures of Health Information HFS 3806J (pdf)
Request to Restrict Uses and Disclosures of Health Information HFS 3806JS (pdf) (Spanish)
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA Privacy Forms Alphabetic Listing
Currently selected
HIPAA Privacy Forms Numeric Listing
Need Assistance?
Report a Webpage Problem