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Elizabeth M. Whitehorn, Director

Provider Notice issued 06/05/14

New Provider Agreements

To:​ Supportive Living Facilities (SLF Only)​
​Date: ​June 5, 2014
​Re: New Provider Agreements​

This notice informs Supportive Living Facilities (SLFs) that Provider Agreements have been revised and that SLFs must complete and return them to Healthcare and Family Services Bureau of Long Term Care.

 

SLFs are required to complete and return both Form HFS 1432B, Long Term Care Provider Agreement - Supportive Living Facility (pdf), and Form HFS 1513 Enrollment Disclosure Statement (pdf).

 

Providers must complete and submit both the Provider Agreement and Enrollment Disclosure Statement by close of business July 30, 2014.

 

Completed documents should be directed to:

 

Healthcare and Family Services
Bureau of Long Term Care – Certification Unit
201 South Grand Avenue East
Springfield, Illinois 62762-0002

If you have any questions concerning this notice contact the Bureau of Long Term Care at 217-782-0545.

 

 

Theresa A. Eagleson, Administrator
Division of Medical Programs