Agencies
Services
Medical Forms Numeric Listing
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- 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 975S - Safety Training Program Application (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 3195 Irrevocable Assignment of Benefits of Life Insurance Policy (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 3437 Medical Claim Inquiry (pdf)
- HFS 3437S Medical Claim Inquiry (Spanish) (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 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)