Form HFS2307 "Hospital, Professional School or Practitioner Owned Group Practice as Alternate Payee" - Illinois

What Is Form HFS2307?

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 April 1, 2010;
  • 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;

Download a fillable version of Form HFS2307 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 HFS2307 "Hospital, Professional School or Practitioner Owned Group Practice as Alternate Payee" - Illinois

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State of Illinois
Department of Healthcare and Family Services
HOSPITAL, PROFESSIONAL SCHOOL OR PRACTITIONER OWNED
GROUP PRACTICE AS ALTERNATE PAYEE
1) The practitioner certifies that he or she is: a) an employee of the hospital or professional school or practitioner owned group
practice and must, as a condition of his or her employment, turn over his or her fee for care or service to Healthcare and Family
Services recipients to the hospital, school, or group practice; OR, b) an independent contractor under contract with the hospital
and under the terms of that contract, the hospital submits the claims to the Department.
2) The practitioner certifies that if the alternate payee designated is a practitioner owned group practice that, all owners, directors,
members or practitioners of the group practice are licensed and eligible to participate, and at this time of application are in good
standing in the Medical Assistance Program of Healthcare and Family Services.
3) The practitioner certifies that if the alternate payee designated is a practitioner owned group practice, that the group practice
shares facilities, equipment and personnel and maintains central patient records.
4) If this form is used for a hospital or school, no bills submitted by the practitioner are for services for which reimbursement has
been made to the hospital or school or for which reimbursement will be sought by submission of a cost report, invoice or
otherwise.
5) Bills submitted will only be for direct patient care rendered or supervised by that practitioner; e.g., services for which the
practitioner assumes full responsibility as specified in Provider Handbooks.
6) The hospital, school or group practice shall be responsible for maintaining and making available to the Department all business
and professional records sufficient to fully and accurately document the nature, scope, detail and receipt of services provided to
Healthcare and Family Services recipients by the provider for whom this form has been submitted. The hospital, school or group
practice shall be responsible for retaining such records for the period required under 89 Illinois Administrative Code 140.28, even
if practitioner leaves the employ or otherwise terminates his or her relationship with the hospital, school or group practice.
7) The hospital, school or group practice will keep and make available to Healthcare and Family Services such records regarding
any payments claimed by the hospital, school or group practice for providing services to Healthcare and Family Services
recipients as the Department may request.
8) The hospital, school or group practice will keep and make available all financial records that may be requested by Healthcare and
Family Services, specifically including records that set forth the terms of the relationship between the hospital, school, or group
practice and its practitioners.
9) The hospital, school or group practice shall have sole financial responsibility for any bills submitted in the name of the practitioner
for which it is the alternate payee. However, if the practitioner owns, directly or indirectly, 5% or more of the shares of stock or
other evidence of ownership in a corporate hospital, school or group practice, or is an investor, owner or partner of the hospital,
school, or group practice, the practitioner and the hospital, school or group practice are jointly and severally liable and
responsible. This responsibility includes liability to repay any overpayments made by the Department. By signing this form the
hospital, school, or group practice expressly authorizes Healthcare and Family Services to withhold overpayments from
payments made by the Department, either as direct payments to the hospital, school, or group practice or made based on the
hospital, school, or group practice being an alternate payee.
10) In the event the alternate payee designated on this form is not a licensed hospital, professional school or practitioner owned
group practice, both the practitioner and the alternate payee designated understand and acknowledge that they shall be
personally liable and responsible, jointly and severally, for any bills submitted to Healthcare and Family Services even though
such bills were prepared, signed and/or submitted solely by the alternate payee or the alternate payee's agent. Liability
hereunder shall include any civil and/or criminal liability, including but not limited to liability under the theory of accountability and
liability for repayment of any overpayment received by the designated alternate payee, plus any penalty provided by statute.
11) The practitioner shall be responsible for the accuracy and truthfulness of all bills submitted on behalf of the practitioner. Bills
submitted in the practitioner's name will be signed by him or her personally or by an authorized agent pursuant to a power of
attorney. This power of attorney must be executed on Form HFS 2306 which shall be submitted to the Department prior to
submittal of any bills signed by the agent. Practitioner understands and acknowledges that it is his or her personal responsibility
to review any and all billings before such billings are submitted to Healthcare and Family Services on practitioner's behalf and/or
in his or her name.
12) The parties signing this document acknowledge and agree that payments will be directed to the alternate payee for all dates of
service beginning
and thereafter (insert date no earlier than sixty days prior to submission of this
document to the Department).
(See Reverse Side)
HFS 2307 (R-4-10)
Page 1 of 2
State of Illinois
Department of Healthcare and Family Services
HOSPITAL, PROFESSIONAL SCHOOL OR PRACTITIONER OWNED
GROUP PRACTICE AS ALTERNATE PAYEE
1) The practitioner certifies that he or she is: a) an employee of the hospital or professional school or practitioner owned group
practice and must, as a condition of his or her employment, turn over his or her fee for care or service to Healthcare and Family
Services recipients to the hospital, school, or group practice; OR, b) an independent contractor under contract with the hospital
and under the terms of that contract, the hospital submits the claims to the Department.
2) The practitioner certifies that if the alternate payee designated is a practitioner owned group practice that, all owners, directors,
members or practitioners of the group practice are licensed and eligible to participate, and at this time of application are in good
standing in the Medical Assistance Program of Healthcare and Family Services.
3) The practitioner certifies that if the alternate payee designated is a practitioner owned group practice, that the group practice
shares facilities, equipment and personnel and maintains central patient records.
4) If this form is used for a hospital or school, no bills submitted by the practitioner are for services for which reimbursement has
been made to the hospital or school or for which reimbursement will be sought by submission of a cost report, invoice or
otherwise.
5) Bills submitted will only be for direct patient care rendered or supervised by that practitioner; e.g., services for which the
practitioner assumes full responsibility as specified in Provider Handbooks.
6) The hospital, school or group practice shall be responsible for maintaining and making available to the Department all business
and professional records sufficient to fully and accurately document the nature, scope, detail and receipt of services provided to
Healthcare and Family Services recipients by the provider for whom this form has been submitted. The hospital, school or group
practice shall be responsible for retaining such records for the period required under 89 Illinois Administrative Code 140.28, even
if practitioner leaves the employ or otherwise terminates his or her relationship with the hospital, school or group practice.
7) The hospital, school or group practice will keep and make available to Healthcare and Family Services such records regarding
any payments claimed by the hospital, school or group practice for providing services to Healthcare and Family Services
recipients as the Department may request.
8) The hospital, school or group practice will keep and make available all financial records that may be requested by Healthcare and
Family Services, specifically including records that set forth the terms of the relationship between the hospital, school, or group
practice and its practitioners.
9) The hospital, school or group practice shall have sole financial responsibility for any bills submitted in the name of the practitioner
for which it is the alternate payee. However, if the practitioner owns, directly or indirectly, 5% or more of the shares of stock or
other evidence of ownership in a corporate hospital, school or group practice, or is an investor, owner or partner of the hospital,
school, or group practice, the practitioner and the hospital, school or group practice are jointly and severally liable and
responsible. This responsibility includes liability to repay any overpayments made by the Department. By signing this form the
hospital, school, or group practice expressly authorizes Healthcare and Family Services to withhold overpayments from
payments made by the Department, either as direct payments to the hospital, school, or group practice or made based on the
hospital, school, or group practice being an alternate payee.
10) In the event the alternate payee designated on this form is not a licensed hospital, professional school or practitioner owned
group practice, both the practitioner and the alternate payee designated understand and acknowledge that they shall be
personally liable and responsible, jointly and severally, for any bills submitted to Healthcare and Family Services even though
such bills were prepared, signed and/or submitted solely by the alternate payee or the alternate payee's agent. Liability
hereunder shall include any civil and/or criminal liability, including but not limited to liability under the theory of accountability and
liability for repayment of any overpayment received by the designated alternate payee, plus any penalty provided by statute.
11) The practitioner shall be responsible for the accuracy and truthfulness of all bills submitted on behalf of the practitioner. Bills
submitted in the practitioner's name will be signed by him or her personally or by an authorized agent pursuant to a power of
attorney. This power of attorney must be executed on Form HFS 2306 which shall be submitted to the Department prior to
submittal of any bills signed by the agent. Practitioner understands and acknowledges that it is his or her personal responsibility
to review any and all billings before such billings are submitted to Healthcare and Family Services on practitioner's behalf and/or
in his or her name.
12) The parties signing this document acknowledge and agree that payments will be directed to the alternate payee for all dates of
service beginning
and thereafter (insert date no earlier than sixty days prior to submission of this
document to the Department).
(See Reverse Side)
HFS 2307 (R-4-10)
Page 1 of 2
CERTIFICATION
The parties to this agreement hereby certify under penalty of perjury that they are in compliance with 89 Illinois Administrative Code, Section
140.24 (d), in that: a) The medical practitioner has a contractual/salary arrangement, as a condition of employment with a hospital or
professional school; b) The medical practitioner is part of a practitioner owned group practice consisting of three or more fulltime licensed
practitioners or the equivalent thereof; c) The medical practitioner is employed by a practitioner who requires, as a condition of employment,
that the fees be turned over to the employer; d) The medical practitioner has a contractual/salary arrangement or is employed by a
governmental entity that requires, as a condition of employment that the fees be turned over to the governmental entity; e) The medical
practitioner has a contractual/salary arrangement or is employed by a community mental health agency that is certified by the Department of
Human Services under 59 Illinois Administrative Code, Ch. IV, Part 132 and is enrolled as a provider in the Illinois Medical Assistance
Program; f) The medical practitioner has a contractual/salary arrangement or is employed by a Federally Qualified Health Clinic that is enrolled
as a provider in the Illinois Medical Assistance Program. If at any time any of the conditions of this agreement are modified, the parties will
immediately notify Healthcare and Family Services.
The parties acknowledge that false, inaccurate or incomplete information is grounds for cancellation of this alternate payee agreement or
denial or termination of participation in the Medical Assistance Program and criminal and/or civil prosecution.
TO BE COMPLETED BY PRACTITIONER
(Signature of Practitioner)
(Date)
(Provider #)
(Individual National Provider Identifier-NPI)
(Printed Name)
(SSN)
TO BE COMPLETED BY PAYEE
The payee certifies that the following owners/stock holders own 5% or more of the stock/shares in the payee=s interest. If additional space
is needed for names, please use separate page. If there is no information to disclose, write NONE on PRINTED NAME line. This section
MUST be completed for enrollment purposes and an entry is required.
(PRINTED NAME)
(SSN)
(% OF OWNERSHIP)
(PRINTED NAME)
(SSN)
(% OF OWNERSHIP)
(Signature of Payee Representative)
(Date)
(Print Name of Payee Representative)
(DMERC #)
Organization/Biller/Payee
(Name of Hospital, Professional School, Practitioner Owned Group Practice,
National Identifier - NPI
FQHC, Community Mental Health Agency or Government Entity)
(CHECK ONE)
Hospital
Hospital Affiliated
Professional School
Partnership
Government Entity
Practitioner Owned Group Practice (List all Practitioners, Names and SSN regardless of percentage of ownership on
separate page).
FQHC Provider Number
Community Mental Health Agency Provider Number
Corporation registered with Secretary Of State whose shares of ownership are publicly traded in a recognized stock
exchange within the USA.
(Doing Business As name, if applicable)
(Tax #)
(Mailing address where payment is to be sent)
(Telephone)
Check Box. If practitioner Office Address should be changed to the Payee Address shown above.
This Alternate Payee Request is (Check One Box and Circle Affected Payee Number):
Add
Change
PAYEE
1
2
3
4
5
6
7
8
9
Print Form
HFS 2307 (R-4-10)
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