Form HFS1662 "Primary Care Physician/Pharmacy Authorization (Non-emergency Services Only)" - Illinois

What Is Form HFS1662?

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 May 1, 2014;
  • 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 HFS1662 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 HFS1662 "Primary Care Physician/Pharmacy Authorization (Non-emergency Services Only)" - Illinois

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State of Illinois
Department of Healthcare and Family Services
PRIMARY CARE PHYSICIAN/PHARMACY AUTHORIZATION
(Non-Emergency Services Only)
Section A: To be completed by the primary care physician or pharmacy for referral to another provider for the
provision of necessary services or goods which the primary care physician or pharmacy cannot provide. It is not to
be given to the patient. Prior arrangements are to be made for referred services.
The original form is to be forwarded to the referred provider with a copy maintained in the prescribing physician's
or pharmacy's record.
Patient Name:
Recipient Number:
Referred Provider Name:
Referred Provider Address:
Reason for Referral:
Date of Appointment:
Authorization:
Primary Care Physician
month / day / year
or Pharmacy Signature
Date Medication Prescribed:
Address:
Date of Referral:
Telephone:
month / day / year
REFERRED PROVIDER RESULTS
Section B: To be completed by the referred provider
Diagnosis:
Treatment/Medication/Goods Dispensed:
Additional Treatment Necessary:
Yes
No
If yes, specify:
Signature:
Date:
A copy of this form is to be maintained in the patient's record. The original is to be forwarded with this invoice for
services rendered to:
Illinois Department of
Healthcare and Family Services
P.O. Box 19118
Springfield, IL 62794-9118
If additional services are indicated, you will receive another authorization to provide these services.
HFS 1662 (R-5-14)
State of Illinois
Department of Healthcare and Family Services
PRIMARY CARE PHYSICIAN/PHARMACY AUTHORIZATION
(Non-Emergency Services Only)
Section A: To be completed by the primary care physician or pharmacy for referral to another provider for the
provision of necessary services or goods which the primary care physician or pharmacy cannot provide. It is not to
be given to the patient. Prior arrangements are to be made for referred services.
The original form is to be forwarded to the referred provider with a copy maintained in the prescribing physician's
or pharmacy's record.
Patient Name:
Recipient Number:
Referred Provider Name:
Referred Provider Address:
Reason for Referral:
Date of Appointment:
Authorization:
Primary Care Physician
month / day / year
or Pharmacy Signature
Date Medication Prescribed:
Address:
Date of Referral:
Telephone:
month / day / year
REFERRED PROVIDER RESULTS
Section B: To be completed by the referred provider
Diagnosis:
Treatment/Medication/Goods Dispensed:
Additional Treatment Necessary:
Yes
No
If yes, specify:
Signature:
Date:
A copy of this form is to be maintained in the patient's record. The original is to be forwarded with this invoice for
services rendered to:
Illinois Department of
Healthcare and Family Services
P.O. Box 19118
Springfield, IL 62794-9118
If additional services are indicated, you will receive another authorization to provide these services.
HFS 1662 (R-5-14)