Illinois Department of Healthcare and Family Services Forms

This Form is used for submitting health insurance claims in the state of Illinois.

This form is used for completing a knee brace questionnaire in the state of Illinois.

This form is used for obtaining a certificate of medical necessity for an external insulin infusion pump in the state of Illinois.

This form is used for completing a questionnaire related to a prosthesis in the state of Illinois. It collects information to assist in determining eligibility and coverage for prosthesis-related services.

This form is used for completing a questionnaire and ordering a Neuromuscular Electrical Stimulator (NMES) in Illinois.

This form is used for long term care providers in Illinois who operate state-operated facilities. It outlines the agreement between the provider and the state for providing care to individuals.

This form is used for submitting transportation invoices in the state of Illinois.

This document is used for submitting Medicare crossover invoices in Illinois. It allows healthcare providers to claim reimbursement for services provided to patients who are eligible for both Medicare and Medicaid.

This form is used for reporting progress on negative pressure wound therapy in the state of Illinois.

This type of document is used for providers in Illinois to participate in the Illinois Medical Assistance Program.

This form is used for submitting a questionnaire to request a home apnea monitor in Illinois.

This Form is used for assessing wound measurements in the state of Illinois.

This form is used for gathering information through a questionnaire about home phototherapy in the state of Illinois.

Este formulario se utiliza para solicitar pagos relacionados con servicios de aborto en Illinois.

Este formulario se utiliza para solicitar una exención por dificultades en el estado de Illinois.

This document is a form used to request the payment of premiums, deductibles, and Medicare fees by mail in the state of Illinois.

This form is used for requesting access to the Integrated Eligibility System (IES) in the state of Illinois.

Este formulario se utiliza para enviar un aviso al Departamento de Personas de Edad Avanzada (IDOA) en Illinois.

Este formulario se utiliza para solicitar beneficios de salud para trabajadores con discapacidades en Illinois.

This form is used for requesting prior authorization to refill a prescription too soon in the state of Illinois.

This document is used for obtaining consent for sterilization in the state of Illinois, and it is in Spanish.

This form is used for attesting to information in the state of Illinois.

This Form is used for declaring identity in the state of Illinois.

This Form is used for authorizing automatic deposits in Illinois.

This form is used for providing important disclosure statement regarding legal representation in Illinois.

This document provides instructions for making payments in the state of Illinois. It includes information on how to complete the payment form and where to submit it.

This Form is used for making a declaration of good faith in Illinois. It is written in Spanish.

This document is a form for the state of Illinois that contains important information regarding the disclosure of legal representation.

This Form is used for applying for Child Support Services (Title IV-D) in the state of Illinois.

Este formulario se utiliza para solicitar servicios de manutención de niños en Illinois. Puede ser utilizado por padres que deseen solicitar servicios de manutención de sus hijos.

This form is used for making payment remittance to the State Disbursement Unit (SDU) in Illinois.

Este formulario se utiliza para solicitar servicios de manutención de niños en Illinois en virtud del Título IV-D.

This Form is used for applying for Child Support Services (Title IV-D) in Illinois if the parent is not living with the child/children.

This form is used for requesting a certified copy of the Voluntary Acknowledgment of Paternity and/or Denial of Paternity in the state of Illinois.

This form is used for notifying the state of Illinois when a Spanish-speaking child is placed in a non-Spanish speaking living arrangement.