Form HFS1435 "Nursing Facility Traumatic Brain Injury (Tbi) Notification" - Illinois

What Is Form HFS1435?

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, 2012;
  • 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 HFS1435 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 HFS1435 "Nursing Facility Traumatic Brain Injury (Tbi) Notification" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Nursing Facility Traumatic Brain Injury (TBI) Notification
Completion of this form is required for notification to the Department to start or discontinue payment to
nursing facilities for TBI services. A copy of the physician order sheet identifying the need for TBI
services, and the Rancho Los Amigos Cognitive Assessment identifying score Level IV-X, as applicable,
for the identified resident must be attached before payment for TBI services will authorized. Form must be
resubmitted as resident advances to another Tier.
Facility Name:
Facility Address:
City
Provider Number:
Resident Name:
Recipient Identification Number:
Birth Date:
Admit Date:
Effective Date of TBI Coverage:
at
Tier I
Tier II
Tier III
Physician Order Sheet Identifying Need for TBI Services Attached.
Rancho Los Amigos Cognitive Assessment Identifying Score Level IV-X, As Applicable.
Discontinue TBI Coverage Effective Date:
Reason TBI Coverage is Discontinued (check one):
Exceeds Tier Time Limit Prescribed by Rule
Discharged from Facility
Died
I certify that all entries on this form are true, accurate, and complete and meet all the requirements of the
Illinois Department of Healthcare and Family Services.
Date
Signature of Facility Administrator or Authorized Agent
Send completed document to: Department of Healthcare and Family Services, Bureau of Long Term
Care, 201 S. Grand Avenue East, Springfield, Illinois 62763 or fax to 217/524-7114.
HFS 1435 (N-4-12)
State of Illinois
Department of Healthcare and Family Services
Nursing Facility Traumatic Brain Injury (TBI) Notification
Completion of this form is required for notification to the Department to start or discontinue payment to
nursing facilities for TBI services. A copy of the physician order sheet identifying the need for TBI
services, and the Rancho Los Amigos Cognitive Assessment identifying score Level IV-X, as applicable,
for the identified resident must be attached before payment for TBI services will authorized. Form must be
resubmitted as resident advances to another Tier.
Facility Name:
Facility Address:
City
Provider Number:
Resident Name:
Recipient Identification Number:
Birth Date:
Admit Date:
Effective Date of TBI Coverage:
at
Tier I
Tier II
Tier III
Physician Order Sheet Identifying Need for TBI Services Attached.
Rancho Los Amigos Cognitive Assessment Identifying Score Level IV-X, As Applicable.
Discontinue TBI Coverage Effective Date:
Reason TBI Coverage is Discontinued (check one):
Exceeds Tier Time Limit Prescribed by Rule
Discharged from Facility
Died
I certify that all entries on this form are true, accurate, and complete and meet all the requirements of the
Illinois Department of Healthcare and Family Services.
Date
Signature of Facility Administrator or Authorized Agent
Send completed document to: Department of Healthcare and Family Services, Bureau of Long Term
Care, 201 S. Grand Avenue East, Springfield, Illinois 62763 or fax to 217/524-7114.
HFS 1435 (N-4-12)