Form HFS2316 "Limited Power of Attorney" - Illinois

What Is Form HFS2316?

This is a legal form that was released by the Illinois Department of Healthcare and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2009;
  • The latest edition provided by the Illinois Department of Healthcare and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HFS2316 by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

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Download Form HFS2316 "Limited Power of Attorney" - Illinois

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State of Illinois
Department of Healthcare and Family Services
LIMITED POWER OF ATTORNEY
I,
, do hereby make and appoint
Name of Facility's Administrator (Printed)
Name of Agent
as my true and lawful attorney in fact for me and in my name solely for the purpose of signing the Billing
Certification located on the last page of Form HFS 194-M-1, Remittance Advice, and Form HFS 2234, Bed
Reserve Form.
The agent is employed at the facility and will, before signing Form HFS 194-M-1, assure the accuracy of the
payment received.
This limited power of attorney shall remain in effect until such time as the Illinois Department of Healthcare and
Family Services is notified in writing that it has been revoked.
This authorization in no way limits the facility's or my rights, liabilities or duties relating to the provisions of service
under the Illinois Department of Healthcare and Family Services Medical Assistance Program. I accept full
responsibility for all payments received from the Illinois Department of Healthcare and Family Services under my
name on Form HFS 194-M-1 and Form HFS 2234.
Name of Facility
Address of Facility
Signature of Facility Administrator
Date
Date
Signature of Agent
Printed Name of Agent
HFS 2316 ( R-11-09)
Print Form
State of Illinois
Department of Healthcare and Family Services
LIMITED POWER OF ATTORNEY
I,
, do hereby make and appoint
Name of Facility's Administrator (Printed)
Name of Agent
as my true and lawful attorney in fact for me and in my name solely for the purpose of signing the Billing
Certification located on the last page of Form HFS 194-M-1, Remittance Advice, and Form HFS 2234, Bed
Reserve Form.
The agent is employed at the facility and will, before signing Form HFS 194-M-1, assure the accuracy of the
payment received.
This limited power of attorney shall remain in effect until such time as the Illinois Department of Healthcare and
Family Services is notified in writing that it has been revoked.
This authorization in no way limits the facility's or my rights, liabilities or duties relating to the provisions of service
under the Illinois Department of Healthcare and Family Services Medical Assistance Program. I accept full
responsibility for all payments received from the Illinois Department of Healthcare and Family Services under my
name on Form HFS 194-M-1 and Form HFS 2234.
Name of Facility
Address of Facility
Signature of Facility Administrator
Date
Date
Signature of Agent
Printed Name of Agent
HFS 2316 ( R-11-09)
Print Form