Form HFS2536 "Interagency Certification of Screening Results" - Illinois

What Is Form HFS2536?

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 July 1, 2005;
  • 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 HFS2536 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 HFS2536 "Interagency Certification of Screening Results" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Interagency Certification Of Screening Results
Name:
Birth Date:
Social Security #:
Address:
Medicaid Eligible:
Y
or
N
Case #, if known:
Facility Name:
Address:
Recipient #, if known:
Date of screening:
Determination of Need Score:
NOTE: Screening is valid for 90 days from date of screening.
Date of admission to facility:
Admission to nursing facility or supportive living facility occurred prior to the date of screening and one of the following
circumstances existed:
Placed from out-of-state; or
Hospital Emergency/Outpatient Services; or
Pre-existing condition of need for a caregiver and caregiver is no longer able to provide care.
Explain reason for loss of caregiver (must be completed):
The individual was screened to determine his/her need for nursing facility, supportive living or ICF/DD services and to
ascertain if other services might be an acceptable alternative to nursing facility, supportive living or ICF/DD placement.
Screening indicated supportive living services are appropriate.
Screening indicated ICF/DD services are appropriate.
Screening indicated nursing facility services are appropriate.
Screening indicated nursing facility, supportive living or ICF/DD services are not appropriate.
SCREENING CERTIFIED BY:
Department on Aging
Department of Human Services Check One:
Division of Rehabilitation Services
Division of Developmental Disability
Division of Mental Health
Illinois Department of Healthcare and Family Services
Signature of Individual Certifying Results
Title
Date
Agency/Office
Phone Number
HFS 2536 (R-7-05)
State of Illinois
Department of Healthcare and Family Services
Interagency Certification Of Screening Results
Name:
Birth Date:
Social Security #:
Address:
Medicaid Eligible:
Y
or
N
Case #, if known:
Facility Name:
Address:
Recipient #, if known:
Date of screening:
Determination of Need Score:
NOTE: Screening is valid for 90 days from date of screening.
Date of admission to facility:
Admission to nursing facility or supportive living facility occurred prior to the date of screening and one of the following
circumstances existed:
Placed from out-of-state; or
Hospital Emergency/Outpatient Services; or
Pre-existing condition of need for a caregiver and caregiver is no longer able to provide care.
Explain reason for loss of caregiver (must be completed):
The individual was screened to determine his/her need for nursing facility, supportive living or ICF/DD services and to
ascertain if other services might be an acceptable alternative to nursing facility, supportive living or ICF/DD placement.
Screening indicated supportive living services are appropriate.
Screening indicated ICF/DD services are appropriate.
Screening indicated nursing facility services are appropriate.
Screening indicated nursing facility, supportive living or ICF/DD services are not appropriate.
SCREENING CERTIFIED BY:
Department on Aging
Department of Human Services Check One:
Division of Rehabilitation Services
Division of Developmental Disability
Division of Mental Health
Illinois Department of Healthcare and Family Services
Signature of Individual Certifying Results
Title
Date
Agency/Office
Phone Number
HFS 2536 (R-7-05)