CFC Forms - NEW or REVISED 02/2014

New or Revised CFC Forms as of February, 2014:

• Acknowledgement and Notice of Provisional Provider Status (pdf)
• Acknowledgement to Decline Exemption for Tax Savings Account (pdf)
• CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates (pdf)
• Consent to Use Personally Identifiable Information (PII) & Bill Public Benefits (pdf)
• Consent to Use Private Insurance/Healthcare Plan Benefits & Assignment of Right (pdf)
• Early Intervention to Early Childhood Transition Tracking Instructions and Form (pdf)
• Family Participation Fees Program Fact Sheet (pdf)
• Intake/Social History Summary Sheet (pdf)
• Request for Due Process Hearing Officer (pdf)
• Request for Mediation (pdf)
• Notice of System of Payments & Fees (pdf)
• Provisional Provider Authorization Request (pdf)
• Provisional Provider Request (pdf)

NOTE:  All other forms remain the same as when released in January 2013.

Contact Information

If you are in need of an accessible version of a form(s), please contact:

• Jenni Grissom
  IDHS - Bureau of Early Intervention
  823 East Monroe
  Springfield, IL 62701
  Phone:  217/524-1596
  Email: jennifer.grissom@illinois.gov