Form HFS3411A "Mch Primary Care Provider Agreement" - Illinois

What Is Form HFS3411A?

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 January 1, 2006;
  • 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 HFS3411A 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 HFS3411A "Mch Primary Care Provider Agreement" - Illinois

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State of Illinois
Department of Healthcare and Family Services
MCH Primary Care Provider Agreement
PROVIDER INFORMATION
Last Name, First Name, Middle Initial
Provider Number
License Number
Office Address
State
City
Zip Code
Fax Number
Office Phone
After Hours Phone
My Specialties Include: (Check all that apply)
General Practice
OB/GYN
Pediatrics
Family Practice
Internist
Advance Practice Nurse (APN)
I Hold Hospital Admitting Privileges at the Following Hospitals:
Note: APN's list hospitals where collaborating physician(s) have admitting privileges.
Delivery Priviliges
Hospital Name
Hospital Address
HFS Use Only
Yes
No
My Other Practice Locations Include:
Note: APN's list practice locations for collaborating physician(s).
Physician or Clinic Name
Street Address/City/State/Zip
Phone
Certification
I certify that I meet the participation requirements of an MCH Primary Care Provider, as cited in Section B of the
reverse page. I also understand that I must notify the Department in writing should any changes to the information
contained herein become necessary. I also understand that the information I enter on this form will be used to
update the Department's data base.
Requested Agreement Effective Date:
Date
Provider Signature
Please mail your original signed copy to: Healthcare & Family Services
For more information,
Provider Participation Unit
call: (217) 782-0538
P. O. Box 19114
Springfield, Illinois 62794-9114
HFS 3411A (R-1-06)
State of Illinois
Department of Healthcare and Family Services
MCH Primary Care Provider Agreement
PROVIDER INFORMATION
Last Name, First Name, Middle Initial
Provider Number
License Number
Office Address
State
City
Zip Code
Fax Number
Office Phone
After Hours Phone
My Specialties Include: (Check all that apply)
General Practice
OB/GYN
Pediatrics
Family Practice
Internist
Advance Practice Nurse (APN)
I Hold Hospital Admitting Privileges at the Following Hospitals:
Note: APN's list hospitals where collaborating physician(s) have admitting privileges.
Delivery Priviliges
Hospital Name
Hospital Address
HFS Use Only
Yes
No
My Other Practice Locations Include:
Note: APN's list practice locations for collaborating physician(s).
Physician or Clinic Name
Street Address/City/State/Zip
Phone
Certification
I certify that I meet the participation requirements of an MCH Primary Care Provider, as cited in Section B of the
reverse page. I also understand that I must notify the Department in writing should any changes to the information
contained herein become necessary. I also understand that the information I enter on this form will be used to
update the Department's data base.
Requested Agreement Effective Date:
Date
Provider Signature
Please mail your original signed copy to: Healthcare & Family Services
For more information,
Provider Participation Unit
call: (217) 782-0538
P. O. Box 19114
Springfield, Illinois 62794-9114
HFS 3411A (R-1-06)
Illinois Department of Healthcare and Family Services
MCH
Primary Care Provider Agreement
This Agreement pertains only to the relationship of the Illinois Department of Healthcare and Family Services with the Provider
under the Department's MCH (Maternal and Child Health) Program. This Agreement does not affect any other relationship or
agreement, including but not limited to, the general Provider Agreement, between the Department and the Provider.
Section A: Department Responsibilities
In partnership with the Provider named herein, the Department agrees to:
• pay enhanced rates for delivery services;
• pay enhanced rates for preventive and primary care office visits provided to children;
• provide expedited processing of claims with enhanced rates for Providers who meet established criteria;'
• upon request, furnish client eligibility and profiles of prior services reimbursed by the Department;
• provide support services as needed for the purpose of client follow-through on treatment regimen;
• facilitate access to medical care for clients in cooperation with the case manager through the local health
department , community-based organization or certified clinic under one of the State's programs.
Section B: Participation Requirements
As a Provider in the MCH Program, I agree to:
• maintain hospital admitting privileges, or for APNs maintain a collaborative agreement with a physician who has
hospital admitting privileges;
• provide periodic health screenings (EPSDT) and primary pediatric care as needed;
• provide obstetrical care, delivery services, as appropriate;
• perform risk assessment for children, pregnant women or both;
• maintain 24-hour telephone coverage for consultation including ensuring that "sick" children and "at-risk" pregnant
women are treated as needed, based on triage of need;
• schedule diagnostic consultation and specialty visits or contact the designated case management entity to
coordinate/schedule the visit as appropriate;
• provide equal access to medical care for clients in cooperation with the Department or its designated case
management entity;
• communicate with the case management entity;
• provide a medical home for children, pregnant women or both.
Special Provisions:
You may terminate your participation as a Primary Care Provider in the MCH Program upon written notice sent to
the:
Healthcare & Family Services
Provider Participation Unit
P.O. Box 19114
Springfield, Illinois 62794-9114
The Department may terminate a Provider's participation as a Primary Care Provider in the MCH Program
under this Agreement if the provider fails to maintain any of the above participation requirements. Such
termination shall not be subject to the Department's rules and regulations on notice and hearing for a
Provider's termination from participation in the Medical Assistance Program.
HFS 3411A (R-1-06)
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