Illinois Department of Healthcare and Family Services Forms

This form is used for redetermining Medicaid eligibility and renewing medical benefits in Illinois.

This Form is used for granting someone limited power of attorney in the state of Illinois.

This form is used for healthcare providers to apply for enrollment in the Medical Assistance Program in Illinois.

This form is used for applying for financial assistance to cover the cost of an abortion in Illinois.

This form is used for obtaining certification as an Advance Practice Nurse (APN) in Illinois. It also includes a collaborative agreement form for APNs.

This form is used for completing a questionnaire related to binaural hearing aids in the state of Illinois.

This form is used for requesting a review of payment for long-term care services in Illinois.

This form is used for authorizing a primary care physician or pharmacy to provide non-emergency services in the state of Illinois.

This Form is used for requesting prior approval in Illinois. It provides instructions for completing the Form HFS1409.

This Form is used for providers to enroll in the Illinois Medical Assistance Program. It provides instructions on how to fill out the application and become a registered provider.

This form is used for ordering cranial remolding orthosis or cranial cervical orthosis for the treatment of congenital torticollis type in Illinois.

This form is used for filing a discrimination claim in Illinois for clients or applicants who believe they have been treated unfairly.

This form is used for tenants in Illinois to complete a questionnaire in order to continue renting an airway clearance device.

This form is used for reporting compliance with the Civil Rights Act Title VI for skilled nursing, intermediate care, and other 24-hour facilities in Illinois.

This Form is used for submitting invoices to the health agency in Illinois.

This Form is used for applying to the health benefits program for workers with disabilities in Illinois through mail-in application.

This form is used for completing a questionnaire related to hospital beds in Illinois.

This Form is used for Hospital, Professional School or Practitioner Owned Group Practice in Illinois to designate an Alternate Payee for payments.

This form is used for Illinois residents to request payment for an inappropriate level of care.

This form is used for the interagency certification of screening results in the state of Illinois. It is used to verify the results of screening procedures conducted by multiple agencies.

This form is used for seating and mobility evaluation in the state of Illinois.

This form is used for completing a questionnaire about special decubitus mattresses in Illinois.

This form is used for submitting invoices for laboratory or portable X-ray services in the state of Illinois.

This Form is used for gathering information about manual wheelchairs in Illinois.

This Form is used for filing a late affidavit in Illinois.

This form is used for requesting a long-term care bed reserve or reporting a temporary absence for individuals in Illinois.

This form is used for transmitting third-party liability payments for long-term care facilities in Illinois.

This form is used for submitting a statement of hardship to request a waiver of the penalty period in Illinois.

This form is used for individuals in Illinois to provide their statement of identity. It may be required for various purposes such as applying for government benefits or verifying personal information.

This form is used for obtaining consent for sterilization procedures in the state of Illinois.

This form is used for primary care providers in Illinois to enter into an agreement with a Managed Care Health Plan (MCH).

This form is used for conducting medical equipment and supplies invoice in the state of Illinois. It is designed to document and track the costs and details of medical equipment and supplies provided to patients or healthcare facilities.

This form is used for notifying individuals in Illinois about their involuntary discharge from the Supportive Living Program.

This form is used for healthcare providers in Illinois to enter into an agreement to participate in the Illinois Medical Assistance Program.

This form is used for notifying the Illinois nursing facility about a traumatic brain injury (TBI) case.

This form is used for ordering optical prescriptions in the state of Illinois.

Este formulario se utiliza para recopilar información financiera adicional de las personas que solicitan cuidado a largo plazo en Illinois.

This form is used for requesting provider forms in the state of Illinois. It is a document that providers can submit to request specific forms that they need for their practice.

This document is a checklist used in Illinois to review and assess augmentative communication systems. It helps evaluate the effectiveness of these systems in aiding communication for individuals with disabilities.