Form HFS 1706G Integrated Eligibility System (Ies) Access Request - Illinois

Form HFS1706G or the "Integrated Eligibility System (ies) Access Request" is a form issued by the Illinois Department of Healthcare and Family Services.

Download a PDF version of the Form HFS1706G down below or find it on the Illinois Department of Healthcare and Family Services Forms website.

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State of Illinois
Department of Healthcare and Family Services
INTEGRATED ELIGIBILITY SYSTEM (IES) ACCESS REQUEST
PART 1 - ACTION REQUESTED
Internal
External
Add New User
Delete User
Change User Info
Transfer User
PART 2 - ACTION REQUESTED
Requestor Name:
E-mail Address:
Phone Number:
Requestor RACF ID:
Active Directory ID:
Payroll ID:
Gender:
Male
Female
Job Title:
Type of Employee:
Requested IES Office:
Employee Role:
Supervisor:
If Transfer/Change, Previous Office:
Work Location Name:
Work Address (Street & City):
Birth Month (2-digit): Birth Date (2-digit):
Last Four of SSN:
Non-HFS Employee:
Contract Start Date
Contract End Date
TO BE COMPLETED FOR ALL ACTIONS EXCEPT “DELETE CURRENT USER”
I, the undersigned, am hereby advised and understand that my use of data processing facilities or resources for any purpose other than official Department
business is strictly forbidden by state law. Any unauthorized usage of the data processing facilities or resources may be cause for severe disciplinary action.
Further, I understand that data processing facilities or resources include, but are not limited to, mainframe, Personal Computers (PC'S), laptops or any other
HFS computer equipment used in some aspect of data processing including terminals (irrespective of geographic location), software of any type, and/or
programming. Further, unauthorized use includes but is not limited to, preparation and/or execution of games, or any non-work related activities. Further,
I understand that State and Federal laws and Department policy prohibits disclosure or discussion of any recipient information or other confidential information
with anyone outside the Department without proper authorization.
Further, I am hereby advised and understand the requirements for non-disclosure of any confidential retention of all passwords or password information
acquired by me whether such information pertains to my individual password or the password(s) of others. I will exercise diligence in the safekeeping of
password information and will report authorized disclosure promptly to HFS Supervision or Management.
Requestor's Signature
Date
PART 3 - APPROVAL
PART 4 - COMPLETED BY
Date
Requesting Supervisor
IES Security Coordinator
Date
Requesting Bureau Chief
Date
(Req'd for Permit)
Division Administrator
Date
REQ'D FOR PERMIT OF NON-HFS EMPLOYEE
HFS 1706G (R-7-16)
State of Illinois
Department of Healthcare and Family Services
INTEGRATED ELIGIBILITY SYSTEM (IES) ACCESS REQUEST
PART 1 - ACTION REQUESTED
Internal
External
Add New User
Delete User
Change User Info
Transfer User
PART 2 - ACTION REQUESTED
Requestor Name:
E-mail Address:
Phone Number:
Requestor RACF ID:
Active Directory ID:
Payroll ID:
Gender:
Male
Female
Job Title:
Type of Employee:
Requested IES Office:
Employee Role:
Supervisor:
If Transfer/Change, Previous Office:
Work Location Name:
Work Address (Street & City):
Birth Month (2-digit): Birth Date (2-digit):
Last Four of SSN:
Non-HFS Employee:
Contract Start Date
Contract End Date
TO BE COMPLETED FOR ALL ACTIONS EXCEPT “DELETE CURRENT USER”
I, the undersigned, am hereby advised and understand that my use of data processing facilities or resources for any purpose other than official Department
business is strictly forbidden by state law. Any unauthorized usage of the data processing facilities or resources may be cause for severe disciplinary action.
Further, I understand that data processing facilities or resources include, but are not limited to, mainframe, Personal Computers (PC'S), laptops or any other
HFS computer equipment used in some aspect of data processing including terminals (irrespective of geographic location), software of any type, and/or
programming. Further, unauthorized use includes but is not limited to, preparation and/or execution of games, or any non-work related activities. Further,
I understand that State and Federal laws and Department policy prohibits disclosure or discussion of any recipient information or other confidential information
with anyone outside the Department without proper authorization.
Further, I am hereby advised and understand the requirements for non-disclosure of any confidential retention of all passwords or password information
acquired by me whether such information pertains to my individual password or the password(s) of others. I will exercise diligence in the safekeeping of
password information and will report authorized disclosure promptly to HFS Supervision or Management.
Requestor's Signature
Date
PART 3 - APPROVAL
PART 4 - COMPLETED BY
Date
Requesting Supervisor
IES Security Coordinator
Date
Requesting Bureau Chief
Date
(Req'd for Permit)
Division Administrator
Date
REQ'D FOR PERMIT OF NON-HFS EMPLOYEE
HFS 1706G (R-7-16)
State of Illinois
Department of Healthcare and Family Services
INTEGRATED ELIGIBILITY SYSTEM (IES) ACCESS REQUEST
DESCRIPTION
ENTRY
PART 1 - ACTION REQUESTED
Requestor is a State employee.
Internal
External
Requestor is not a State employee.
Add New User
Requestor does not have access to IES.
Delete User
Requestor no longer needs access to IES.
Change User Info
Requestor needs a change to IES access.
Transfer User
Requestor is moving to a different agency.
PART 2 - ACTION REQUESTED
Requestor Name
The name of the person requesting access.
E-mail Address
E-mail address of person requesting access.
Requestor RACF ID
Mainframe log-in ID for requestor.
Active Directory ID
Active Directory account for requestor.
Payroll ID
Requestor's payroll ID (EIN).
Type of Employee
Select from drop down menu.
Job Title
Job title of requestor.
Employee Role
Select from drop down menu.
Requested IES Office
Requestor's bureau and name of a user account to mirror.
Supervisor
Name of requestor's supervisor.
Transfer/Change Previous Office
Agency and bureau/office requestor is coming from.
Work Location Name
Requestor's bureau or office name.
Birth Month
Requestor's birth month (for non-HFS employees only).
Birth Date
Requestor's birth day (for non-HFS employees only).
Last Four of SSN
Last 4 numbers of requestor's social security # (non-HFS employees).
Contract Start Date
Non-HFS employee's contract start date.
Contract End Date
Non-HFS employee's contract end date.
PART 3 - APPROVAL
Requesting Supervisor
Signature of requestor's Supervisor.
Requesting Bureau Chief
Signature of requestor's Bureau Chief.
Division Administrator
Signature of requestor's Division Administrator.
PART 4 - COMPLETED BY
IES Security Coordinator
State employee responsible for completing request.
HFS 1706G (R-7-16)

Download Form HFS 1706G Integrated Eligibility System (Ies) Access Request - Illinois

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