Form CFS431-A "Psychotropic Medication Request Fax Cover Sheet" - Illinois

Form CFS431-A or the "Form Cfs431-a "psychotropic Medication Request Fax Cover Sheet" - Illinois" is a form issued by the Illinois Department of Children and Family Services.

The form was last revised in May 1, 2015 and is available for digital filing. Download an up-to-date Form CFS431-A in PDF-format down below or look it up on the Illinois Department of Children and Family Services Forms website.

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Download Form CFS431-A "Psychotropic Medication Request Fax Cover Sheet" - Illinois

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Illinois Department of Children & Family Services
CFS 431-A Cover
DCFS Consent Team / UIC Research Team
Rev 5/2015
Psychotropic Medication Request
Fax Cover Sheet
Date:
Total Pages:
To: DCFS Consent Unit/UIC Research Team: Fax (312) 814-7015 (24-hour fax)
Contact Person
Contact Person Affiliation/Position
Contact Person Phone Number
Extension
Facility Name: (Hospital/Residential Center/DOC/JJ)
Fax Number
Facility Address
From: Agency Name
Agency Phone Number
Agency Fax: Number
Doctor
Doctor Phone Number
Doctor Fax: Number
Doctor Address
Region:
Northern
Central
Southern
Cook
Notes/Comments:
Consent Hotline – 800-828-2179
After Hours (Child Intake and Recovery Unit) - 866-503-0184
This message is intended only for the use of the individual or entity to which it is addressed, and may contain information
that is privileged, confidential, or exempt from disclosure under applicable law. If the reader of the message is not the
intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is
strictly prohibited. If you have received this message in error, please notify us immediately by telephone and return the
original to us at the address below via U.S. mail. Thank you for your cooperation.
Illinois Department of Children & Family Services
CFS 431-A Cover
DCFS Consent Team / UIC Research Team
Rev 5/2015
Psychotropic Medication Request
Fax Cover Sheet
Date:
Total Pages:
To: DCFS Consent Unit/UIC Research Team: Fax (312) 814-7015 (24-hour fax)
Contact Person
Contact Person Affiliation/Position
Contact Person Phone Number
Extension
Facility Name: (Hospital/Residential Center/DOC/JJ)
Fax Number
Facility Address
From: Agency Name
Agency Phone Number
Agency Fax: Number
Doctor
Doctor Phone Number
Doctor Fax: Number
Doctor Address
Region:
Northern
Central
Southern
Cook
Notes/Comments:
Consent Hotline – 800-828-2179
After Hours (Child Intake and Recovery Unit) - 866-503-0184
This message is intended only for the use of the individual or entity to which it is addressed, and may contain information
that is privileged, confidential, or exempt from disclosure under applicable law. If the reader of the message is not the
intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is
strictly prohibited. If you have received this message in error, please notify us immediately by telephone and return the
original to us at the address below via U.S. mail. Thank you for your cooperation.
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