Agencies
Services
General Form
* Important Note: If your experience technical difficulties opening certain fillable PDF's, please right-click the form link, save the PDF to is device, then open to form outdoor about your browser.
Applications
Designating Someone to Help You
Long Term Care
Discrimination Complaint
Supplier
Additional Financial Information used Extended Term Care Applicants HFS 3654 (pdf)
Additional Financial Information for Long Term Attend Applicants HFS 3654S (Spanish) (pdf)
ACH Direct debit Form for Hospital Assesments and GEMT HFS 3848G (pdf)
Acknowledgement of Receipt of Hysterectomy Information HFS 1977 (pdf)
Acknowledgement of Receipt of Hysterectomy Request HFS 1977S (Spanish) (pdf)
Adaptive Attitudes Support Service Prior Authority Form (pdf)
Advancing Practice Nurse (APN) Certification and Collaborate Agreement Formulare HFS 3411C (pdf)
Agreement for Participation is the Ilinois Medical Assistance Program HFS 1413 (pdf)
Appendix E-3b Binaural Hearing Aid Questionnaire HFS 3701I (pdf)
Apply for Payment of Medicare Premiums, Deductibles furthermore Coinsurance HFS 2378M (pdf)
Application for Cash of Medicare Premiums, Deductibles and Coinsurance Spanish HFS 2378MS (pdf)
Adaptive Behavior Sponsor Service Prior Authorization Form (pdf)
Augmentative Communication Systems Assessment Check Cheat HFS 3640 (pdf)
Augmentative Contact Systems Client Assessment Report HFS 3641 (pdf)
Certificate of Medical Necessity for Ex Insulin Infusion Pump HFS 2305F (pdf)
Credential and Attestation for Primary Care Ratings Increase HFS 2352 (pdf)
Citizenship Documents and Your Medizinisches Benefits HFS 3859D (pdf)
Citizenship Documents and Your Medizin Benefits HFS 3859DS(Spanish) (pdf)
Health Aids for Operators with Disabilities (HBWD) Application HFS 2378MB (pdf)
Well-being Uses for Workers with Disabilities (HBWD) Application HFS 2378MBS (pdf)
Medical Insurance State Formulare Example Only HFS 2360 (OCR) (pdf)
Hospital, Specialized School alternatively Group Practice as Alternate Payee HFS 2307 (pdf)
How to Get a Medical Card and a Primary Care Provider (PCP) with Your Babe HFS 4691 (pdf)
Illinois Department on Aging (IDoA) Notification HFS 2538B (pdf)
Illinois Department with Aging (IDoA) Subscription HFS 2538BS (Spanish) (pdf)
Illinlinois Early Intervention Program Mention Fax Back Form HFS 652 (pdf)
- Interagency Documentation away Covering Results HFS 2536 (pdf)
- Involuntary Perform Notice of Appeal and Request for Auditory HFS 3732 (pdf)
- Irrevocably Assignment is Benefits of Life Travel Policy HFS3195(pdf)
Laboratory / Movable X-Ray Your Example Includes HFS 2211 (OCR) (pdf)
Long Terminology Care (SNF/ICF) Provider Monthly Assessment Story HFS 1446 (pdf)
Long Term Taking Bed Reserve/Temporary Absence Form HFS 2234 (pdf)
Long Term Care Facility Third Party Liability (TPL) Payment Transmittal HFS 3461 (pdf)
Prolonged Term Care Provider Agreement State-Operated Attachment (Provider Select 34) HFS 1433 (pdf)
Medicaid Payment of Medicare Shipping Sharing Expenses HFS 3120 (pdf)
Gesundheitswesen Fittings / Supplies Invoice Example Single HFS 2210 (OCR) (pdf)
Medicar/Service Car/Taxicab Uniform Trip Flight HFS 3825 (pdf)
Medicare Savings for Qualified Beneficiaries Brochure HFS 3757 (pdf)
Medicare Savings for Qualified Beneficiaries Brochure HFS 3757 (Spanish) (pdf)
Non-emergency Transportation Fingerprint Form HFS 3819 (pdf)
Notification till HFS of Illinois Medicaid Hospice Benefit Choices HFS 1592 (pdf)
Nursing Assistant Professional plus Competency Evaluation Reimbursement Request HFS 2310 (pdf)
Suckling Facility Traumatic Brain Injury (TBI) Notification HFS 1435 (pdf)
Power Manage Devices and Custom Wheelchair Request Instructions for HFS 3701K (pdf)
Primary Care Provider Authorization (Non-Emergency Services Only) HFS 1662 (pdf)
Prior Approval Request Instructions on HFS 1409 HFS 1409i (pdf)
Progress Report for Negative Pressure Wound Therapy HFS 3785A (pdf)
Provider Enrollment Application in the Medicine Assistance Program HFS 2243 (pdf)
Provider Enrollment Application Instructions for HFS 2243 (pdf)
Provider Forms Request (Springfield) HFS 1517 (pdf) or Online Form Request
Questions and Order for Neuromuscular Electrical Stimulator (NMES) HFS 2305I (pdf)
Questionnaire for Next Mieten of Airway Clearance Device HFS 2305C (pdf)
Questionnaire for Negative Pressure Wound Therapy HFS 3785 (pdf)
Report on Resident off Private Long Term Support Faciltiy HFS 26 (pdf)
Request For Inappropriate Level Of Caution Payment HFS 3127 (pdf)
Screening, Assessment and Evaluation Tool Approval Request Form HFS 724 (pdf)
Standardized Illinois Early Intervention Referral Mold HFS 650 (pdf)
Statement of Hardship - Request for Waiver of Punishment Period HFS 2379WA (pdf)
Statement of Hardship - Request for Waiver of Penalty Period (Spanish) (pdf) HFS 2379 WAS
Dental Prior Approval Request Form Getting for HFS 3701TI (pdf)
UB-04 Instance Only - Not Ship until HFS CMS 1450 (pdf) (OCR)
Using Division on Aged (DoA) Community Care Program (CCP) Services to Meet Spenddown HFS 2538C (pdf)
Waiver How Provider Agreement by Share in To Illinois Medical Assistance Choose HFS 1413A (pdf)
