Form HFS2234 (IL478-1157) "Long Term Care Bed Reserve/Temporary Absence Form" - Illinois

What Is Form HFS2234 (IL478-1157)?

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 November 1, 2008;
  • 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 HFS2234 (IL478-1157) 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 HFS2234 (IL478-1157) "Long Term Care Bed Reserve/Temporary Absence Form" - Illinois

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Illinois Department of
Healthcare and Family Services
Long Term Care
Document Control Number
Bed Reserve/Temporary Absence Form
Facility Name
Facility Number
Facility Address
Facility City
State
Zip
Facility Reference Number
Recipient Number
Recipient Name
First
Last
Bed Reserve Information
Type
Begin Date
End Date
Type
Begin Date
End Date
I certify that all entries on this form are true, accurate, complete and meet all the rquirements of the Illinois Department
of Healthcare and Family Services.
___________________________________________________________
________________________________
Signature of Certifying or Operating Officer of Authorized Agent
Date
HFS 2234 (R-11-08)
IL478-1157
State of Illinois
IOCI 0470-09
Illinois Department of
Healthcare and Family Services
Long Term Care
Document Control Number
Bed Reserve/Temporary Absence Form
Facility Name
Facility Number
Facility Address
Facility City
State
Zip
Facility Reference Number
Recipient Number
Recipient Name
First
Last
Bed Reserve Information
Type
Begin Date
End Date
Type
Begin Date
End Date
I certify that all entries on this form are true, accurate, complete and meet all the rquirements of the Illinois Department
of Healthcare and Family Services.
___________________________________________________________
________________________________
Signature of Certifying or Operating Officer of Authorized Agent
Date
HFS 2234 (R-11-08)
IL478-1157
State of Illinois
IOCI 0470-09