Form Hfs 1517 PDF Details

The Illinois Department of Healthcare and Family Services is a critical junction for medical providers within the state, chiefly concerning the submission and management of various healthcare-related claims and requests. The HFS 1517 form emerges as a vital document in this bureaucratic yet essential landscape, serving as a comprehensive request form for providers seeking different types of healthcare forms. Designed to streamline the order process, it covers a wide array of documents, from drug invoices and Medicare crossover forms to transportation and medical equipment invoices. The form provides an evident reflection of the department's effort to adapt to the digital age, promoting the use of online submissions through the Medical Electronic Data Interchange and Internet Electronic Claims system – a significant leap aimed at enhancing efficiency through technological solutions. Equally important is the detail-oriented approach the form adopts, requiring specific information such as provider Medicaid numbers, addresses, and intended quantities, thus ensuring precision in form delivery and handling. Its facilitation of both physical and electronic submissions addresses varied provider preferences, marking a thoughtful effort towards accessibility and convenience in the realm of healthcare administration.

QuestionAnswer
Form NameForm Hfs 1517
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshfs1517 il478 form

Form Preview Example

Illinois Department of Healthcare and Family Services

2946 Old Rochester Road

Springfield, Illinois 62703-5659

Online Forms Request: http://www.hfs.illinois.gov/forms/

Fax Number: (217) 557-3459

Please note that claims may be submitted through the department’s Medical Electronic Data Interchange, Internet Electronic Claims (MEDI/IEC) System at: http://www.myhfs.illinois.gov This electronic feature allows providers to submit claims directly to the department through Internet browser software with no additional hardware or software.

PROVIDER FORMS REQUEST

TYPE OR PRINT ALL ENTRIES

ORDER REQUEST DATE: ______________________ PROVIDER MEDICAID NUMBER: _____________________________

PROVIDER NAME: _______________________________________________________

STREET ADDRESS: ______________________________________________________ (CANNOT DELIVER TO POST OFFICE BOX)

CITY/STATE/ZIP: ________________________________ PHONE #: (_____) _____ -_______ ATTENTION OF: _____________________

PROVIDER E-MAIL ADDRESS: __________________________________ (Optional)

Enter the quantity of the forms being requested in increments of 100. Please be sure to indicate the total number of individual forms or envelopes needed in the Quantity column, not the number of boxes, cases or packages.

HFS Form Number:

QUANTITY:

Envelope Number:

QUANTITY:

215CF Drug Invoice, (Continuous Feed Format)

__________

824MCR Medicare Crossover

__________

1409

Prior Approval Request

__________

1414

Special Approval

__________

1443

Provider Invoice, (Single Sheet)

__________

1415

Drug Invoice

__________

1443CF Provider Invoice, (Continuous Feed Format)

__________

1416

Adjustments

__________

2209

Transportation Invoice, (Single Sheet)

__________

1444

Provider Invoice Envelope

__________

2209CF Transportation Invoice, (Continuous Feed Format)

__________

2244

Transportation Invoice

__________

2210

Medical Equipment / Supplies Invoice, (Single Sheet)

__________

2246

Health Agency Invoice

__________

2210CF Medical Equipment / Supplies Invoice, (Cont. Feed Format) __________

2247

Medical Equipment Supplies

__________

2211

Laboratory / Portable X-Ray Invoice, (Single Sheet)

__________

2248

NIPS Special Invoice Handling

__________

2211CF Laboratory / Portable X-Ray Invoice, (Cont. Feed Format)

__________

2294

Equip/Supplies Prior Approval

__________

2212

Health Agency Invoice, (Single Sheet)

__________

2300

Prior Approval Request

__________

2212CF Health Agency Invoice, (Continuous Feed Format)

__________

Additional Forms Needed, Not Listed Above:

2360

Health Insurance Claim Form, (Single Sheet)

__________

__________________________

__________

2360CF Health Insurance Claim Form, (Continuous Feed Format)

__________

__________________________

__________

3797

Medicare Crossover Invoice (Single Sheet)

__________

__________________________

__________

3797CF Medicare Crossover Invoice, (Continuous Feed Format)

__________

__________________________

__________

Submit this form by fax or mail to the address listed above.

HFS 1517 (R-9-10)

IL478-1023

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