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Medical Forms
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Applications
Designating Someone to Help You
Long Term Care
Discrimination Complaint
Providers
Additional Financial Information for Long Term Care Applicants HFS 3654 (pdf)
Additional Financial Information for Long Term Care 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 Information HFS 1977S (Spanish) (pdf)
Adaptive Behavior Support Service Prior Authorization Form (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)
Appendix E-3b Binaural Hearing Aid Questionnaire HFS 3701I (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)
Adaptive Behavior Support Service Prior Authorization Form (pdf)
Augmentative Communication Systems Assessment Review Checklist HFS 3640 (pdf)
Augmentative Communication Systems Client Assessment Report HFS 3641 (pdf)
Certificate of Medical Necessity for External Insulin Infusion Pump HFS 2305F (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)
Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MB (pdf)
Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MBS (pdf)
Health Insurance Claim Form Example Only HFS 2360 (OCR) (pdf)
Hospital, Professional School or Group Practice as Alternate Payee HFS 2307 (pdf)
How to Get a Medical Card and a Primary Care Provider (PCP) for Your Baby HFS 4691 (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)
- Interagency Certification of Screening Results HFS 2536 (pdf)
- Involuntary Discharge Notice of Appeal and Request for Hearing HFS 3732 (pdf)
- Irrevocable Assignment of Benefits of Life Insurance Policy HFS3195(pdf)
Laboratory / Portable X-Ray Invoice Example Only HFS 2211 (OCR) (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 Third Party Liability (TPL) Payment Transmittal HFS 3461 (pdf)
Long Term Care Provider Agreement Supportive Living Facility (Provider Type 28) HFS 1432B (pdf)
Long Term Care Provider Agreement State-Operated Facility (Provider Type 34) HFS 1433 (pdf)
Medicaid Payment of Medicare Cost Sharing Expenses HFS 3120 (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 HFS 3757 (Spanish) (pdf)
Non-emergency Transportation Fingerprint Form HFS 3819 (pdf)
Notification to HFS of Illinois Medicaid Hospice Benefit Election HFS 1592 (pdf)
Nursing Assistant Training and Competency Evaluation Reimbursement Request HFS 2310 (pdf)
Nursing Facility Traumatic Brain Injury (TBI) Notification HFS 1435 (pdf)
Power Mobility 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 for HFS 1409 HFS 1409i (pdf)
Progress Report for Negative Pressure Wound Therapy HFS 3785A (pdf)
Provider Enrollment Application in the 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
Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES) HFS 2305I (pdf)
Questionnaire for Continued Rental of Airway Clearance Device HFS 2305C (pdf)
Questionnaire for Negative Pressure Wound Therapy HFS 3785 (pdf)
Report on Resident of Private Long Term Care Faciltiy HFS 26 (pdf)
Request For Inappropriate Level Of Care Payment HFS 3127 (pdf)
Screening, Assessment and Evaluation Tool Approval Request Form HFS 724 (pdf)
Standardized Illinois Early Intervention Referral Form HFS 650 (pdf)
Statement of Hardship - Request for Waiver of Penalty Period HFS 2379WA (pdf)
Statement of Hardship - Request for Waiver of Penalty Period (Spanish) (pdf) HFS 2379 WAS
Therapy Prior Approval Request Form Instructions for HFS 3701TI (pdf)
UB-04 Example Only - Not Supplied by HFS CMS 1450 (pdf) (OCR)