Form HFS2305C "Questionnaire for Continued Rental of Airway Clearance Device" - Illinois

What Is Form HFS2305C?

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 February 1, 2015;
  • 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 HFS2305C 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 HFS2305C "Questionnaire for Continued Rental of Airway Clearance Device" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Questionnaire for Continued Rental of Airway Clearance Device
Patient Name:
DOB:
RIN:
1. Has the patient been hospitalized for a respiratory condition
since use of the airway clearance device was started?
Yes
No
If yes, provide copies of all discharge summaries.
2. Has the patient required any antibiotics for respiratory
No
exacerbations since the airway clearance device was started?
Yes
If yes, how many times?
3. Has the number of emergency room, urgent care, and office
visits related to exacerbation of the respiratory conditions
No
No change
decreased since starting the airway clearance device?
Yes
4. Do the patient and caregivers feel the patient's respiratory
secretions are more easily expelled with use of the airway
clearance device?
Yes
No
No change
5. Has the patient's respiratory status improved
since using the airway clearance device?
Yes
No
No change
6. Has use of the therapy vest increased
adherence to airway clearance therapy?
Yes
No
No change
Date
Practitioner's Signature with degree:
Office Phone #:
Fax:
NPI:
Page of
HFS 2305C (N-2-15)
State of Illinois
Department of Healthcare and Family Services
Questionnaire for Continued Rental of Airway Clearance Device
Patient Name:
DOB:
RIN:
1. Has the patient been hospitalized for a respiratory condition
since use of the airway clearance device was started?
Yes
No
If yes, provide copies of all discharge summaries.
2. Has the patient required any antibiotics for respiratory
No
exacerbations since the airway clearance device was started?
Yes
If yes, how many times?
3. Has the number of emergency room, urgent care, and office
visits related to exacerbation of the respiratory conditions
No
No change
decreased since starting the airway clearance device?
Yes
4. Do the patient and caregivers feel the patient's respiratory
secretions are more easily expelled with use of the airway
clearance device?
Yes
No
No change
5. Has the patient's respiratory status improved
since using the airway clearance device?
Yes
No
No change
6. Has use of the therapy vest increased
adherence to airway clearance therapy?
Yes
No
No change
Date
Practitioner's Signature with degree:
Office Phone #:
Fax:
NPI:
Page of
HFS 2305C (N-2-15)