XI. Appendices - Forms and Instructions

Rights

• Choice of Supports and Services (English Version) (pdf) (IL462-1238)
• Choice of Supports and Services (Spanish Version) (pdf) (IL462-1238S)
• Release of Information (English Version) (pdf) (IL462-1214)
• Release of Information (Spanish Version) (pdf) (IL462-1214S)
• Rights of Individuals (IL462-1201)
• Notice of Individual's Right to Appeal (English Version) (pdf) (IL462-1202)
• Notice of Individual's Right to Appeal (Spanish Version) (pdf) (IL462-1202S)
• Reporting of Unusual Incidents (Restraint/Seclusion) by Child Group Home Providers (CFS 119) 

Authorization/Prior Approval/Termination For Individuals

• Application for Individual Service Authorization (pdf) (IL462-1248)
• Individual/Guardian Information Form (pdf) (IL462-2026)
• Bed Hold Extension Request (pdf) (IL462-2027)
• Medicaid Waiver Therapy Prior Approval Request (pdf) (IL462-1302)
• Medicaid Waiver Temporary Assistance (53C) Prior Approval
• Adaptive Equipment/Assistive Technology/Home and Vehicle Modification Request Cover Sheet (pdf) (IL462-1301)
• Service Termination Approval Request (pdf) (IL462-2028)
• Crisis Funding Information Request (pdf) (IL462-0140)

Provider Information/Enrollment

• Instructions on How To Obtain Your National Provider Identification Number (NPI)
• Waiver Provider Agreement Medical Program (pdf) (HFS 1413A)
• Instructions for HFS 1413A
• Provider Enrollment Application (HFS 2243) (pdf)
• Instructions for HFS 2243
• Provider Types and Categories Of Service
• Payee Designation/Authorization  (pdf) (IL462-1180)
• Authorization For Background Check (pdf) (CFS 689 - English Version)
• Authorization For Background Check (pdf) (CFS 689S - Spanish Version)
• Request for Taxpayer Identification and Certification (pdf) (IRS W9)
  • All payee entities (including individual transportation providers and all other professionals, agencies and companies that plan to be reimbursed directly by the Illinois State Comptroller) must complete this U.S. Internal Revenue Service form. 
  • The legal name and FEIN/FTIN or SSN on the W9 must match the name and FEIN/FTIN or SSN on the provider enrollment application (HFS 2243 and on the Provider Agreement (HFS 1413A).
• Provider Information Form (pdf) (IL462-1246)

Billing/Documentation

• Correcting Individual Case Information & Rejected Fee-For-Service Bills 
• DD and MH Fee-For-Service Programs - Request For Payment - Billing By Provider - Hourly (pdf)   (IL462-1178)
• Instructions for IL462-1178 (Hourly Billing)
• DD and MH Fee-For-Service Programs - Request For Payment - Billing By Provider - Per Diem (pdf)  (IL462-1179)
• Instructions for IL462-1179  (Per Diem)
• DD and MH Fee-For-Service Programs - Request For Payment - Billing By Provider - Event (pdf)  (IL462-1177)
• Instructions for IL462-1177 (Per Event)
• Day Program Daily Attendance Record (pdf) (IL462-1303)
• Day Program Monthly Attendance Summary (pdf) (IL462-1304)
• HBS Service Agreement (pdf) (IL462-2029)

Other

• Notice of DHS Community-Based Services (pdf) (HFS 2653)
• Instructions for HFS 2653 
• Redetermination of Medicaid DD Waiver Eligibility (pdf) (IL462-0952)