Form Hfs 1156 – Fill Out and Use This PDF

The HFS 1156 form serves as a critical notification tool for long-term care facilities in Illinois, enabling them to inform the Department of Healthcare and Family Services about key events such as admissions, discharges, and deaths among residents. This form, necessary for maintaining accurate and up-to-date information, plays a pivotal role in ensuring that changes in a client's status are promptly reported to aid in the continuity of their eligibility and care provision. For those who require guidance on completing this form or wish to ensure its accuracy, click the button below to access comprehensive assistance.

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Form Hfs 1156 PDF Details

The State of Illinois, through its Department of Healthcare and Family Services, mandates the use of the HFS 1156 form, a crucial document designed for long-term care (LTC) and supported living facilities (SLF). This form serves as a comprehensive notification system for various client transitions and financial changes that could influence their eligibility for further assistance or services. Facilities are required to report key events such as admissions, discharges, deaths, changes in Medicare coverage, insurance details, and alterations in the client's income. It encapsulates detailed information ranging from the client's personal data, admission and discharge details, to specifics regarding their Medicare and insurance coverage, and even updates on the client's income and financial status upon discharge or death. The purpose behind meticulously recording and reporting this information within five days of any change is to ensure that the Illinois Department of Human Services (DHS) Family Community Resource Center (FCRC) can accurately maintain continuing eligibility and support for clients amid changing circumstances. Moreover, this protocol emphasizes the importance of transparency and timely communication between care facilities and the overseeing governmental bodies, ensuring that clients' needs and eligibility statuses are efficiently tracked and managed.

Question	Answer
Form Name	Form Hfs 1156
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	ICF, SLF, hfs 1156 form, HFS

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State of Illinois

Illinois Department of Healthcare and Family Services

LONG TERM CARE FACILITY NOTIFICATION

To:

From:

Client Name

Recipient Number:

Case Number:

SSN:

Social Security Claim Number

Birth Date:

Place of Birth: State:

City:

County:

1. ADMISSION

Admission Date:

From:

Hospital

Community

SLF

Other LTC Facility

Previous Address:

Client receives or will receive hospice services

Yes

Admitting Diagnosis (ICD-9 Code):

Attending Physician Name:

Attending Physician Number:

Level of Care (Check One):

SNF

ICF

ICF/MR

SLF

SLF Dementia Unit

2. DISCHARGE

Discharge Date:

Community

Other LTC Facility

SLF

General Hospital

State Operated Facility

To:

Left State/County

Unknown

CILA

Other

New Address:

3. DEATH

Date of Death:

Body Released To:

4. COMPLETE THIS SECTION ONLY WHEN REPORTING A DISCHARGE OR DEATH

Personal Funds Balance on the Day of Discharge or Death:

Amount of Other Funds on the Day of Discharge or Death:

Room & Board Balance on the Day of Discharge or Death:

Client

Relative

Administrator of Estate

Other

Funds were Given to:

Name/Relationship/Address:

Amount: $

5. MEDICARE (Check as appropriate)

Full Medicare Covered SNF Services: Begin Date:

End Date:

Medicare Coinsurance:

Begin Date:

End Date:

HFS 1156 (R-11-11)

LONG TERM CARE FACILITY NOTIFICATION

6. INSURANCE COVERAGE (TPL)

(e.g. name of company, change in coverage, change in premium):

7. RECEIPT OF LONG TERM CARE INSURANCE (TPL) PAYMENT

Date Received:

Amount: $

Dates Covered by Payment:

Date and Amount of TPL Funds, if any, Returned to Client: Date:

Amount: $

Date and Amount of Group Care Credit Funds, if any, Returned to Client: Date:

Amount: $

8. INCOME (Check as appropriate)

Change in Income:

Previous Monthly Amount: $

Date Last Received:

Current Monthly Amount: $

Date Last Received:

Source:

Receipt of Income:

Monthly Amount: $

Source:

Date First Received:

Receipt of Sum: Amount: $

Source:

Date Received:

9. REMARKS

HFS 26 Attached:

Signature/Title:

Yes

HFS 2536 Attached:

Yes

Date:

INSTRUCTIONS FOR COMPLETION

PURPOSE: The HFS 1156 is used by the LTC or SLF facility to notify the Department of Human Services (DHS) Family Community Resource Center (FCRC) of admission, discharge, death or other changes in circumstances of a client which could have an effect on continuing eligibility. When changes in the client’s circumstances occur, this notice must be forwarded to the DHS FCRC within five days of the change. Since reserve bed days do not affect eligibility, it is not necessary to complete this form to report absences for hospitalization or therapeutic home visits.

1.Check if reporting a new admission. Enter all information for this item.

2.Check if reporting a discharge. Enter all information for this item.

3.Check if reporting a death. Enter all information for this item.

4.Check as appropriate when reporting a discharge or death. Enter all information for this item. Do not delay submittal of this form because the client’s funds have not been disbursed. Enter the balance of funds on the day of discharge or death. If none, enter “0”. Enter name/relationship/address of persons to whom funds were given and the amount disbursed. Enter “0” if the funds have not been disbursed as of the date the form is completed.

5.Check if reporting a change to or from Medicare coverage. Enter all information for this item.

6.Check if reporting new insurance coverage or a change in existing coverage.

7.Check if reporting receipt of long term care insurance coverage.

8.Complete if reporting a change in the client’s income. Complete upon receipt of information or as changes occur. Check as appropriate and enter necessary information.

9.This section is completed to convey additional information for which no other space is provided on the form (e.g., funds in excess of $2000). Complete as needed.

The form must be signed and dated by the person to whom the facility has assigned the responsibility for reporting changes in a client’s circumstances.

HFS 1156 (R-11-11)

How to Edit Form Hfs 1156 Online for Free

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Step 2: This tool will allow you to modify almost all PDF files in a variety of ways. Modify it by including customized text, adjust existing content, and put in a signature - all when you need it!

When it comes to blanks of this precise form, here is what you want to do:

1. Begin filling out the SLF with a number of necessary blank fields. Get all of the important information and make sure not a single thing omitted!

2. Once your current task is complete, take the next step – fill out all of these fields - DISCHARGE, Discharge Date, Community, Other LTC Facility, SLF, General Hospital, State Operated Facility, Left StateCounty, Unknown, CILA, Other, New Address, DEATH, Date of Death, and Body Released To with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

3. The following segment is about Room Board Balance on the Day of, Funds were Given to, Client, Relative, Administrator of Estate, Other, NameRelationshipAddress, Amount, MEDICARE Check as appropriate, Full Medicare Covered SNF Services, Medicare Coinsurance, Begin Date, End Date, End Date, and HFS R - type in all of these empty form fields.

Many people frequently make errors when completing End Date in this area. Make sure you read twice everything you enter here.

4. You're ready to proceed to this fourth section! Here you will get all of these INSURANCE COVERAGE TPL, eg name of company change in, RECEIPT OF LONG TERM CARE, Date Received, Amount, Dates Covered by Payment, Date and Amount of TPL Funds if, Date, Amount, Date and Amount of Group Care, Date, Amount, INCOME Check as appropriate, Change in Income, and Previous Monthly Amount form blanks to do.

5. To wrap up your form, the particular area includes several extra blank fields. Typing in HFS Attached, Yes, HFS Attached, Yes, SignatureTitle, Date, INSTRUCTIONS FOR COMPLETION, PURPOSE The HFS is used by the, because the clients funds have not, Check if reporting a change to or, and enter necessary information, This section is completed to, and Complete as needed should wrap up everything and you're going to be done in a flash!

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Form Hfs 1156 – Fill Out and Use This PDF

Form Hfs 1156 PDF Details

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