XIII. 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)
• IL462-1201 S - Medicaid Derechos del IndividuoExoneración DD - Servicios Basados en el Hogar y en la Comunidad de (pdf)
• Notice of Individual's Right to Appeal (English Version) (pdf) (IL462-1202)
• Reporting of Unusual Incidents (Restraint/Seclusion) by Child Group Home Providers (CFS 119) (pdf) 

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)) (IL 462-2027)
• 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)
• CILA Application (pdf) (IL462-4425)
• CILA Application Instructions (pdf) (IL462-4425 instructions)

Provider Information/Enrollment

• Instructions on How To Obtain Your National Provider Identification Number (NPI)
• Waiver Provider Agreement Medical Program (pdf) (HFS 1413A)
• Waiver Provider Agreement Instructions for Individual Professional  (HFS 1413A)
• Waiver Provider Agreement Instructions for Agencies (HFS 1413a)
• Waiver Provider Enrollment Application (pdf)  (HFS 2243)
• Waiver Provider Enrollment Application Instructions  (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 Spanish (pdf) (CFS 689S - Spanish Version)
• Request for Taxpayer Identification and Certification (pdf) (IRS W9)
• 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)
• IL462-2029 - Home-Based Support Services (HBS) Service Agreement (pdf) 
• IL462-2029 S - Acuerdo Para Servicios - Servicios De Apoyo Basados En El Hogar (HBS) (pdf)

Other

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