Search Forms

Helping Families. Supporting Communities. Empowering Individuals.
  • Search Forms by Name/Number, in the "Form" field enter all or part of the form name, all of the form number, or the last portion of the form number after the hyphen (e.g., enter Responsibilities, IL444-0360, or 0360)
  • Search Forms by Division, leave the "Form Name" field blank and choose the desired division from the "Division" field.
  • Search Forms Help

Results

  1. IL444-0020 - FOID Inpatient Provider Registration Form (pdf) - (N-4-08)
  2. IL444-0021 - FOID Nursing Home Provider Reporting Registration Form (pdf) - (N-4-08)
  3. IL444-0022 - FOID Provider User I.D. & System Access Request (pdf) - (N-1-08)
  4. IL444-2022 - Community Provider User ID and System Access Request (pdf) - (R-05-16)
  5. IL444-2768 - Enrollment/Disenrollment Form (pdf) - (R-10-11)
  6. IL462-0007 - Statement of Ill. Law on Advance Directives (pdf) - (R-1-01)
  7. IL462-0007 S - DECLARACIÓN DE LA LEY EN ILLINOIS SOBRE INSTRUCCIONES ANTICIPADAS (pdf) - (R-1-01)
  8. IL462-0013 - Notice of Treatment Panel Meeting for Medication Review (pdf) - (R-1-10)
  9. IL462-0016 - Reaffirmation of Voluntary Status (pdf) - (R-8-12)
  10. IL462-0016 S - Reafirmación De Su Estado Voluntario En Un Centro Administrado Por El Estado (pdf) - (R-8-12)
  11. IL462-0033 - Medication Adminstration/Documentation Incident Report (pdf) - (R-7-10)
  12. IL462-0068 S - INFORMACIÓN Y PETICIÓN PARA AVISO SOBRE LIBERTAD CONDICIONAL O CUANDO SALGA EN LIBERTAD LA PERSONA (pdf) - (N-06-13)
  13. IL462-0068 - Information and Request for Notification of the Conditional Release or Discharge of a Person (pdf) - (N-06-13)
  14. IL462-0104 - OIG Training Registration Form (pdf) - (R-03-16)
  15. IL462-0130 - Qualified Intellectual Disabilities Professional (QIDP) Job & Educational Requirements: Checklist A (pdf) - (R-12-16)
  16. IL462-0131 - Basic Qualified Intellectual Disabilities Professional (QIDP) Training Program Letter of Application: Checklist B (pdf) - (R-12-16)
  17. IL462-0132 - Basic Qualified Intellectual Disabilities Professional (QIDP) Training Program Letter of Application: Checklist C (pdf) - (R-12-16)
  18. IL462-0133 - Qualified Intellectual Disabilities Professional (QIDP) Training Instructor Qualifications: Checklist D (pdf) - (R-12-16)
  19. IL462-0134 - Qualified Intellectual Disabilities Professional (QIDP) Orientation Training Core Competency Area Checklist (pdf) - (R-12-15)
  20. IL462-0135 - Qualified Intellectual Disabilities Professionals (QIDP) Training Program Course Content Review Guide (pdf) - (R-12-15)
  21. IL462-0136 - Request for Online Qualified Intellectual Disabilities Professional (QIDP) Training Program Competency Matrix (pdf) - (R-12-15)
  22. IL462-0140 - Crisis Transition Plan and Funding Request (pdf) - (R-1-13)
  23. IL462-0146 - Authorization to Disclose/Obtain Information - (R-04-16)
  24. IL462-0146 A - Authorization for Release of Information and Assignment of Benefit (pdf) - (R-6-02)
  25. IL462-0146 AS - Autorización Para Revelar Información Y Traspaso de Beneficios (pdf)
  26. IL462-0146 S - Autorización Para Revelar/Obtener Información (pdf) - (R-6-08)
  27. IL462-0159 - Instructions for LIGAS Transition Service Plan (pdf) - (R-10-14)
  28. IL462-0159 - LIGAS Transition Service Plan (pdf) - (R-10-14)
  29. IL462-0160 - LIGAS Transition Service Plan - Modified Version Instructions (pdf) - (N-07-13)
  30. IL462-0170 S - Waiver Program Provider Agreement (pdf) - (N-09-15)
  31. IL462-0170 Waiver Program Provider Agreement (pdf) - (N-09-15)
  32. IL462-0401 - Accredition, Licensure and Certification Survey Report Form (pdf) - (N-1-02)
  33. IL462-0723 - PROVIDER / AGENCY / PAYEE INFORMATION UPDATE FORM (pdf) - (R-09-16)
  34. IL462-0952 - Redetermination of Medicaid DD Waiver Eligibility (pdf) - (R-1-08)
  35. IL462-0953 - CERTIFIED BEHAVIOR ANALYST - BEHAVIOR INTERVENTION and TREATMENT - LEVEL 1 CERTIFICATION VERIFICATION: CHECKLIST A (pdf) - (R-12-16)
  36. IL462-0954 - CERTIFIED BEHAVIOR ANALYST- BEHAVIOR INTERVENTION and TREATMENT - LEVEL 2 CERTIFICATION VERIFICATION: CHECKLIST B (pdf) - (R-12-16)
  37. IL462-0955 - BEHAVIOR THERAPY (Autism Spectrum Disorder) BEHAVIOR INTERVENTION and TREATMENT - LEVEL 2 APPLICATION COURSEWORK and EXPERIENCE REQUIREMENTS: CHECKLIST C (pdf) - (R-12-16)
  38. IL462-0956 - CERTIFIED RELATIONSHIP DEVELOPMENT INTERVENTION- BEHAVIOR INTERVENTION and TREATMENT - LEVEL 2 CONSULTANT CERTIFICATION VERIFICATION: CHECKLIST D (pdf) - (R-12-16)
  39. IL462-0957 - LICENSED CLINICAL PSYCHOLOGIST - BEHAVIOR INTERVENTION and TREATMENT - LEVEL 1 LICENSE VERIFICATION: CHECKLIST E (pdf) - (R-12-16)
  40. IL462-0958 - EARLY INTERVENTION SPECIALIST COURSEWORK and EXPERIENCE REQUIREMENTS: BEHAVIOR INTERVENTION and TREATMENT LEVEL 2 CHECKLIST F (pdf) - (R-12-16)
  41. IL462-1177 - Fee-for-Service Programs - Request for Payment - Billing by Provider - Event (pdf) - (N-1-08)
  42. IL462-1178 - Fee-For-Service Programs - Request for Payment Billing by Provider-Hourly (pdf) - (N-11-07)
  43. IL462-1179 - Fee-For-Service Programs - Request for Payment Billing by Provider-Per Diem (pdf) - (N-11-07)
  44. IL462-1180 - Payee Designation/Authorization Form (pdf) - (R-09-16)
  45. IL462-1201 - RIGHTS OF INDIVIDUALS (pdf) - (R-12-16)
  46. IL462-1201 S - DERECHOS DEL INDIVIDUO (Exoneración DD - Servicios de Medicaid Basados en el Hogar y en la Comunidad) (pdf) - (R-12-16)
  47. IL462-1202 - Notice of Individual's Right to Appeal Medicaid Waiver Determinations (pdf) - (R-01-17)
  48. IL462-1202 S - Aviso Sobre el Derecho de Apelación del Individuo en las Determinaciones con Exenciones del Medicaid (pdf) - (R-01-17)
  49. IL462-1203 - Determination Summary and Presentation and Selection of Service Options (DDPAS-10) (pdf) - (R-12-14)
  50. IL462-1203 S - Resumen De La Determinación, Presentación Y Selección Para Opciones De Servicios (DDPAS-10) (pdf) - (R-10-12)
  51. IL462-1209 - Staff Training Reimbursement Request for ICF/DD Facilities (pdf) - (R-7-10)
  52. IL462-1209 A - Staff Training Reimbursement Request for SNF/PED Facilities (pdf) - (R-7-10)
  53. IL462-1209 B - Staff Training Reimbursement Request for Community Providers (pdf) - (R-7-10)
  54. IL462-1214 - Release of Information (pdf) - (R-12-13)
  55. IL462-1214 S - Revelar Información (pdf) - (R-12-13)
  56. IL462-1238 - Home & Community Based Services for Adults with Developmental Disabilities (Choice of Support & Services) (pdf) - (R-11-07)
  57. IL462-1238 S - Servicios Basados en Hogar y Communidad Para Individuos Con Discapacidades Del Desarrollo (pdf) - (R-11-07)
  58. IL462-1238A - Choice of Supports and Services - Ligas ICF/DD Outreach (pdf) - (N-8-13)
  59. IL462-1246 - Provider Information (pdf) - (N-2-08)
  60. IL462-1248 - Application for Individual Service Authorization (pdf) - (R-10-07)
  61. IL462-1280 - Direct Support Person (DSP) Training Program Letter of Application: Checklist G (pdf) - (R-10-16)
  62. IL462-1281 - Direct Support Person (DSP) Training Program Letter of Application: Checklist H (pdf) - (R-10-16)
  63. IL462-1282 - Direct Support Person (DSP) Training Program Instructor Qualifications: Checklist I (pdf) - (R-10-16)
  64. IL462-1283 - Direct Support Person (DSP) Training Program Two Year Review: Checklist J (pdf) - (R-10-16)
  65. IL462-1284 - Direct Support Person (DSP) Training Program Interventional Competencies Evaluation Form (pdf) - (R-10-16)
  66. IL462-1285 - Direct Support Person (DSP) Training Program Informational Competencies Evaluation Form (pdf) - (R-10-16)
  67. IL462-1286 - Direct Support Person (DSP) Training Program Core Competency Area Checklist (pdf) - (R-04-13)
  68. IL462-1287 - Direct Support Person Training Program: Classroom Competency Verification (pdf) - (N-1-12)
  69. IL462-1289 - Request for Online Direct Support Person (DSP) Training Program Competency Matrix (pdf) - (N-11-11)
  70. IL462-1290 - Direct Support Person (DSP) Training Program: Core Competency Verification (pdf) - (R-07-13)
  71. IL462-1291 - Request for Waiver of (DSP) Training Requirements (pdf) - (R-10-16)
  72. IL462-1292 - Illinois Health Care Worker Registry Application Form - Report of Direct Support (DSP) Training (pdf) - (R-03-13)
  73. IL462-1293 - Direct Support Person (DSP) On-The-Job Training Activities (OJT) And Accompanying Competency-Based Training Assessments (CBTA) Form (pdf) - (R-10-16)
  74. IL462-1299 Support Services Teams Referral Form 7/15 (pdf) - (N-04-15)
  75. IL462-1301 - Adaptive Equipment/Assistive Technology/Home & Vehicle Modification Request Cover Sheet (pdf) - (R-4-09)
  76. IL462-1302 - Medicaid Waiver Therapy Prior Approval Request (pdf) - (R-12-08)
  77. IL462-1303 - Day Program Daily Attendance Record (pdf) - (N-12-07)
  78. IL462-1304 - Day Program Monthly Attendance Summary (pdf) - (N-12-07)
  79. IL462-2001 - Rights of Individuals Receiving Mental Health and Developmental Disabilities Services (pdf) - (R-04-14)
  80. IL462-2001 AD Application for Admission to an SODC (pdf) - (R-11-05)
  81. IL462-2001 S - Derechos De Individuos Que Reciben Servicios De Salud Mental Y Discapacidades Del Desarrollo (pdf) - (R-04-14)
  82. IL462-2002 D - Order for Habilitation or Release (pdf) - (R-4-00)
  83. IL462-2004 D - Notice Regarding Restricted of Rights of an Individual (pdf) - (R-07-14)
  84. IL462-2004 M - Notice Regarding Restricted Rights of Individual (pdf) - (R-07-14)
  85. IL462-2004 MS - Aviso Sobre Derechos Restringidos Del Individuo (pdf) - (R-07-14)
  86. IL462-2008 - Order for Detention, Examination, Diagnostic Evaluation (pdf) - (R-7-00)
  87. IL462-2009 - Order for Hearing (pdf) - (R-7-00)
  88. IL462-2012 - Out-Patient Certificate (pdf) - (N-3-11)
  89. IL462-2013 - Petition for Transfer (pdf) - (R-3-01)
  90. IL462-2013 S - Petición Para Traslado (pdf) - (R-3-01)
  91. IL462-2014 - Notice of Transfer Between State-Operated Centers (pdf) - (R-8-12)
  92. IL462-2014 S - Aviso Sobre Traslado Entre Centros Administrados Por El Estado (pdf) - (R-8-12)
  93. IL462-2016 - Physician's Report/Certificate (pdf) - (R-7-00)
  94. IL462-2016 S - Reporte / Certificado Del Médico (pdf) - (R-7-00)
  95. IL462-2018 - Notice of Admission (pdf) - (R-08-15)
  96. IL462-2018 S - Aviso Sobre Admision (pdf) - (R-08-15)
  97. IL462-2019 - Notice of Denial of Admission to a State-Operated Center and Right to Request Review (pdf) - (R-8-12)
  98. IL462-2019 S - Aviso De Negación Para Admisión A Un Centro Administrado Por El Estado Y Derecho A Pedir Una Revisión (pdf) - (R-8-12)
  99. IL462-2020 - Notice of Change in Status (pdf) - (R-7-00)
  100. IL462-2021 - Petition for Discharge (pdf) - (R-7-06)
  101. IL462-2022 - Notice of Discharge From a State-Operated Center (pdf) - (R-08-12)
  102. IL462-2022 S - Aviso Para Darle de Alta - Centro Administrado Por el Estado (pdf) - (R-8-12)
  103. IL462-2023 - Notice of Facility Director Decision (pdf) - (R-7-00)
  104. IL462-2023 S - Aviso Sobre Decisión Del Director De La Institución (pdf) - (R-7-00)
  105. IL462-2025 - Petition for Administration of Psychotropic Medication/Electro Convulsive Therapy (pdf) - (R-6-08)
  106. IL462-2025 S - Petición Para Administración De Medicinas Psicotrópicas / Terapiaelectro Convulsiva (pdf) - (R-6-08)
  107. IL462-2026 - Individual/Guardian Information Form (pdf) - (N-2-08)
  108. IL462-2027 - Bed Hold Extension Request Form (pdf) - (R-03-16)
  109. IL462-2028 - Service Termination Approval Request (pdf) - (R-03-16)
  110. IL462-2029 - Home-Based Support Services (HBS) Service Agreement (pdf) - (R-4-09)
  111. IL462-2029 S - Acuerdo Para Servicios - Servicios De Apoyo Basados En El Hogar (HBS) (pdf) - (R-4-09)
  112. IL462-2203 - Notice of Approval of voluntary or Informal Admission (pdf) - (R-6-12)
  113. IL462-2204 M - Outpatient Application for Minors 12 and Over (pdf) - (R-9-02)
  114. IL462-2204 MS - Solicitud Para Paciente Ambulatorio - Niños De 12 a ños Y Mayores (pdf) - (R-9-02)
  115. IL462-2205 M - Examination of Minor for Admission or Continued Hospitalization (pdf) - (R-11-02)
  116. IL462-2207 M - Petition for Review of Voluntary Admission of a Minor (pdf) - (R-9-02)
  117. IL462-2207 MS - Petición Para Revisar La Admisión Voluntaria De Un Menor (pdf) - (R-9-02)
  118. IL462-2208 M - Order for Treatment or Discharge (pdf) - (R-4-01)
  119. IL462-2210 - Pettion For Involuntary Outpatient Admission (pdf) - (R-11-12)
  120. IL462-2210 S - Petición Para Admisión Ambulatoria Involuntaria (pdf) - (R-11-12)
  121. IL462-3499 - NRI / MHSIP Inpatient Consumer Survey (pdf) - (R-5-06)
  122. IL462-3499 S - Encuesta Para Pacientes Hospitalizados En NRI/MHSIP (pdf) - (R-5-06)
  123. IL462-4000 - Clinical Transition Plan (pdf) - (N-4-11)
  124. IL462-4291 - Order Influenza Outreach Material (pdf) - (N-10-07)
  125. IL462-4292 - MRSA Fact Sheet (pdf) - (N-02-08)
  126. IL462-4293 - Order Form MRSA Fact Sheet (pdf)
  127. IL462-4401 - Request/Approval for RN Nurse - Trainer Status (pdf) - (R-10-15)
  128. IL462-4402 - Program Evaluation - RN Nurse - Trainer Training Program (pdf) - (N-2-10)
  129. IL462-4422 - Case Conference Summary (pdf) - (R-08-14)
  130. IL462-4422 S - RESUMEN DE LA CONFERENCIA DEL CASO (pdf) - (R-08-14)
  131. Il462-4423 - Clinical Need Summary (pdf) - (R-08-14)
  132. Il462-4423 S - RESUMEN DE NECESIDADES CLÍNICAS (pdf) - (R-08-14)
  133. IL462-4424 - Additional Staff Support and 1 or 2 Person CILA Request (pdf) - (R-08-14)
  134. IL462-4425 - Application for 60D CILA Support Services (pdf) - (R-8-14)
  135. IL462-4425 - Application for 60D CILA Support Services Instructions (pdf) - (R-9-12)
  136. IL462-4426 Prior Approval Request for Host Family Services (pdf) - (R-5-12)
  137. IL462-4427 Medication Review (DDPAS-3)(pdf) - (R-9-13)
  138. IL462-4428 - Determination Of Intellectual Disability Or Related Condition & Associated Treatment Needs (DDPAS-5) (pdf) - (R-09-13)
  139. IL462-4429 - Identification of Service Needs (DDPAS-6) (pdf) - (R-01-13)
  140. IL462-4430 Authorization for Release of Information (DDPAS-7) (pdf) - (R-09-13)
  141. IL462-4431 - Guardianship Screen (DDPAS-8) (pdf) - (N-09-13)
  142. IL462-4432 - Retirement From Active Treatment (DDPAS-9) (pdf) - (N-12-12)
  143. IL462-4434 - 24 hr Nursing Care Determination (DDPAS-4) (pdf) - (N-01-13)
  144. IL462-4435 - Intake, Assessment, & Determination Summary (DDPAS-2) (pdf) - (R-09-13)
  145. IL462-4437 - OBRA-1 Initial Screen (pdf) - (N-04-13)
  146. IL462-4437 S - OBRA-1 EVALUACIÓN INICIAL (pdf) - (N-04-13)
  147. IL462-4450 - COMMUNITY INTEGRATED LIVING ARRANGEMENT (CILA) CLOSURE CHOICE FORM (pdf) - (N-11-15)
  148. IL462-4451 Request to Exceed 25-Hour ISSA (Individual Support and Services Agency) Services Cap (pdf) - (N-11-15)
  149. IL462-4452 - INDEPENDENT SERVICE COORDINATION (ISC)?SPECIALIZED ADDITIONAL MONITORING REPORT (pdf) - (N-11-15)
  150. IL462-4453 - INDEPENDENT SERVICE COORDINATION/INDIVIDUAL SERVICE AND SUPPORT ADVOCACY (ISC/ISSA) TRANSFER REQUEST FORM (.pdf) - (N-07-16)
  151. IL462-5228 - Personal Property Receipt (pdf) - (N-6-10)
  152. IL462-5462 - Information & Request for Notification of the Conditional Release or Discharge of a Person (pdf) - (R-10-03)
  153. IL462-5900 - Medicaid Waiver Temporary Assistance (53C) Prior Approval Request (pdf)
  154. IL462-9401 - Revocation of Authorization to Disclose Health Information (pdf) - (R-4-03)
  155. IL462-9402 - Designation or Revocation Personal Representative (pdf) - (R-4-03)
  156. IL462-9602 - Amendment of Medical Record (pdf) - (R-4-03)
  157. IL462-9909 - Facility Review Report (pdf) - (N-08-12)