Form HFS2305M "Knee Brace Questionnaire" - Illinois

What Is Form HFS2305M?

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 February 1, 2015;
  • 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 HFS2305M 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 HFS2305M "Knee Brace Questionnaire" - Illinois

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State of Illinois
Department of Healthcare and Family Services
Knee Brace Questionnaire
Patient Name:
DOB:
RIN:
Patient Height:
Weight:
Select One: Left
Right
Bilateral
Applicable Diagnosis:
Date of onset/injury:
Purpose of Device:
State Medical Necessity:
Previous Procedures/Surgeries Date and Type:
If requesting a custom knee orthosis, explain why a prefabricated knee orthotic or custom fitted orthotic cannot be
considered over a custom fabricated knee orthotic:
Product information:
Attach the following information and a completed HFS 1409, Prior Approval Request Form and practitioner order with
the questionnaire:
• Copy of measurements for custom fittings must be submitted with the request.
• Manufacturer name and acquisition cost with a copy of invoice must be submitted with this request.
Practitioner's Signature with degree:
Date
Office Phone #:
Fax:
NPI:
HFS 2305M (N-2-15)
Page 1 of 1
State of Illinois
Department of Healthcare and Family Services
Knee Brace Questionnaire
Patient Name:
DOB:
RIN:
Patient Height:
Weight:
Select One: Left
Right
Bilateral
Applicable Diagnosis:
Date of onset/injury:
Purpose of Device:
State Medical Necessity:
Previous Procedures/Surgeries Date and Type:
If requesting a custom knee orthosis, explain why a prefabricated knee orthotic or custom fitted orthotic cannot be
considered over a custom fabricated knee orthotic:
Product information:
Attach the following information and a completed HFS 1409, Prior Approval Request Form and practitioner order with
the questionnaire:
• Copy of measurements for custom fittings must be submitted with the request.
• Manufacturer name and acquisition cost with a copy of invoice must be submitted with this request.
Practitioner's Signature with degree:
Date
Office Phone #:
Fax:
NPI:
HFS 2305M (N-2-15)
Page 1 of 1