Illinois Department of Healthcare and Family Services Forms

This form is used for the Subsidized Guardianship (Kingap) case record checklist in Illinois.

This form is used for establishing paternity in the state of Illinois. It is used to legally acknowledge the father of a child and can be helpful in issues related to child support and custody.

This Form is used for applying for a Denial of Parentage in the state of Illinois. It provides instructions on how to complete the form and provide the necessary supporting documentation.

Este formulario se utiliza para solicitar servicios de manutención de niños en Illinois, para el padre o madre que no vive con sus hijos. También conocido como Title IV-D.

This form is used by applicants every year to renew their Medicaid coverage. By filling in this form annually, applicants provide actual information about their income, which can change from year to year.

This form is used for completing a questionnaire related to air fluidized beds in Illinois. It likely collects information about the need for an air fluidized bed and other relevant details.

This document is used for requesting a Certificate of Medical Necessity to continue renting an external insulin infusion pump in the state of Illinois.

This form is used for designating a personal representative in the state of Illinois. It allows you to appoint someone to handle your estate after your death.

This form is used for the non-emergency transportation fingerprint process in Illinois. It is required for individuals seeking employment in the non-emergency transportation field in the state. The form is used to collect and process fingerprints for background checks and ensure the safety of passengers using these services.

This form is used for acknowledging the receipt of information related to a hysterectomy procedure in the state of Illinois.

This Form is used for providers to participate in the Medicaid program in Illinois.

This Form is used for requesting adjustments related to hospital services in the state of Illinois.

This form is used for applying for a hardship waiver in Illinois.

This form is used for completing a questionnaire related to enteral nutrition in the state of Illinois.

This form is used for renewing C-Pap/Bipap equipment in the state of Illinois.

This form is used for completing a questionnaire related to food thickeners in the state of Illinois.

This Form is used for notifying the Illinois Department on Aging (IDoA) in Illinois.

This form is used for screening verification in the state of Illinois.

This form is used for individuals or businesses in Illinois to provide a statement of their efforts in good faith towards achieving a certain goal or objective.

This form is used for long term care facilities in Illinois to notify the appropriate authorities of any changes or updates.

This document is for Illinois nursing facilities and ICF/IID providers of long-term care. It is used to establish an agreement between the facility and the provider.

This form is used for applying for medical benefits through mail in the state of Illinois.

This Form is used for individuals in Illinois who need a motorized wheelchair evaluation. It collects information about the individual's mobility needs and helps determine if they qualify for a motorized wheelchair.

This document is a client assessment report for augmentative communication systems in Illinois. It is used to evaluate and provide recommendations for individuals who require alternative methods of communication.

This form is an example of a provider invoice used in Illinois. It is provided for reference purposes only and is not to be used for actual invoicing.

This form is used for requesting reimbursement for nursing assistant training and competency evaluation in the state of Illinois.

This form is used for completing a questionnaire related to negative pressure wound therapy in the state of Illinois.

This document is used for requesting approval for the Screening, Assessment, and Evaluation Tool in the state of Illinois.

This Form is used for completing a questionnaire related to the use of an airway clearance device in the state of Illinois.

This form is used for completing a questionnaire for individuals in Illinois who are using a Tens unit for pain management.

This form is used for requesting prior approval in Illinois. It is a form that needs to be completed and submitted in order to seek approval for a specific request in the state of Illinois.

This document is a Long Term Care Provider Agreement for a Supportive Living Facility in Illinois. It is a form used for providers of this type of facility to enter into an agreement with the state.

This form is used for providers who wish to participate in the Illinois Medical Assistance Program. It is an agreement that outlines the terms and conditions of their participation in the program.

This Form is used for reporting information about residents in private long-term care facilities in Illinois.

This form is used for making payment to corporate owners or providing assurance in the state of Illinois.

This Form is used for completing a questionnaire related to orthosis in the state of Illinois.

This form is used for providing additional financial information for long-term care applicants in the state of Illinois.

This form is used for recognizing that information about hysterectomy has been received in the state of Illinois. (Spanish)

This document is used for making a referral to the Illinois Early Intervention Program. It is a fax back form that can be used to submit the referral information.