Agencies
Services
Medical Forms Alphabetical Listing
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- 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)
- Irrevocable Assignment of Benefits of Life Insurance Policy HFS3195(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)
- Medical Claim Inquiry HFS 3437 (pdf)
- Medical Claim Inquiry HFS 3437S (Spanish) (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)
- Safety Training Program Application HFS975S (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 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)