Illinois Healthcare and Family Services Illinois Healthcare and Family Services  
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Rod R. Blagojevich, Governor

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  Medical Programs Forms
HFS 2390 Abortion Payment Application
HFS 2390S Abortion Payment Application (Spanish)
HFS 2292 Adjustment Form
HFS 3411C

Advance Practice Nurse (APN) Certification and Collaborative Agreement Form (pdf)

HFS 1413 Agreement for Participation
2378KCC All Kids Application (English)
2378KCCS All Kids Application (Spanish)
HFS 3640 Augmentative Communication Systems Assessment Review Checklist (pdf)
HFS 3641 Augmentative Communication Systems Client Assessment Report (pdf)
HFS 3701F C-PAP/BiPAP Renewal Questionnaire (pdf)
HFS 2240 Equipment Prior Approval Request (pdf)
HFS 1517 Forms Request (Springfield) Online Form Request
HFS 2378MB Health Benefits for Workers with Disabilities (HBWD) Application

HFS 2212

 Health Agency Invoice (pdf)
HFS 2360 Health Insurance Claim Form
HFS 2307 Hospital, Professional School or Group Practice as Alternate Payee Form
HFS 1977 Hysterectomy Information

HFS 2211

 Laboratory / Portable X-Ray Invoice (pdf)
HFS 1156 Long Term Care Facility Notification (pdf)
HFS 2378H Medical Benefits Application Mail-in (pdf)
HFS 2378HS Medical Benefits Application Mail-in (pdf) (Spanish)
HFS 2210 Medical Equipment / Medical Supplies (pdf)
HFS 3797 Medicare Crossover Invoice (pdf)
HFS 3411A MCH Primary Care Provider Agreement
HFS 3867 Motorized Wheelchair Evaluation Form (pdf)
HFS 3819 Non-emergency Transportation Fingerprint Form HFS 3819 (pdf)
HFS 2310 Nursing Assistant Training and Competency Evaluation Reimbursement Request (pdf)
HFS 2306 Power of Attorney
HFS 3701K

Power Mobility Devices (Pmds) And Custom Manual Wheelchairs (pdf)

Instruction for HFS 3701K
HFS 1409 Prior Approval Request
HFS 3785A Progress Report For Specialized Wound Therapy (pdf)
HFS 2243

Provider Enrollment Application

Instruction for HFS 2243
HFS 1443 Provider Invoice
HFS 3785 Questionnaire for Specialized Wound Therapy (pdf)
HFS 3701E Questionnaire for TENS Unit (pdf)
HFS 3082A Refill Too Soon Prior Approval Worksheet
HFS 194-M-2 Remittance Advice
HFS 3082 Request for Drug Prior Approval Form
HFS 3833 Request for Extended Sass Services Form (pdf)
HFS 3701H

Seating/Mobility Evaluation (pdf)

Instruction for HFS 3701H
HFS 3701G Special Decubitus Mattress Questionnaire (pdf)
HFS 2189 Sterilization Consent Form
HFS 2189S Sterilization Consent Form (Spanish)
HFS 1413T Transportation Agreement for Participation HFS 1413T (pdf)
HFS 2209 Transportation Invoice (pdf)
 
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