In the healthcare ecosystem, the coordination of patient care among various providers is crucial for the delivery of comprehensive and efficient medical services. The State of Illinois Department of Healthcare and Family Services has implemented a systematic approach to facilitate this coordination through the HFS 1662 form, designated for Primary Care Physician/Pharmacy Authorization for non-emergency services. This form serves a pivotal role in simplifying the referral process from a primary care physician or pharmacy to another provider for necessary services or goods that the initial care provider cannot furnish. It outlines the steps for making prior arrangements for referred services, ensuring that the referred provider receives all the essential information, including the patient's name, recipient number, the reason for the referral, and the details of the prescribed medication or needed service. Section A of the form is meticulously designed to capture this information, while Section B focuses on the referred provider’s feedback, documenting diagnosis, treatment, and any further care required. Such structured communication is fundamental, not only for maintaining a seamless continuum of care but also for keeping accurate records within the patient's healthcare documentation. Furthermore, the form emphasizes the importance of not distributing it to the patient but rather ensuring it reaches the referred provider directly, with a copy maintained by the prescribing entity and the original sent to the Illinois Department of Healthcare and Family Services. This methodical process underscores the commitment to enhancing patient care coordination across different healthcare settings.
| Question | Answer |
|---|---|
| Form Name | Form Hfs 1662 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | hfs1662 state of illinois primary care provider authorization form |
State of Illinois
Department of Healthcare and Family Services
PRIMARY CARE PHYSICIAN/PHARMACY AUTHORIZATION
Section A: To be completed by the primary care physician or pharmacy for referral to another provider for the provision of necessary services or goods which the primary care physician or pharmacy cannot provide. It is not to be given to the patient. Prior arrangements are to be made for referred services.
The original form is to be forwarded to the referred provider with a copy maintained in the prescribing physician's or pharmacy's record.
Patient Name: |
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Recipient Number: |
Referred Provider Name:
Referred Provider Address:
Reason for Referral:
Date of Appointment: |
Authorization: |
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month / day / year |
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Primary Care Physician |
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or Pharmacy Signature |
Date Medication Prescribed: |
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Address: |
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Date of Referral: |
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Telephone: |
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month / day / year |
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REFERRED PROVIDER RESULTS |
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Section B: To be completed by the referred provider
Diagnosis:
Treatment/Medication/Goods Dispensed:
Additional Treatment Necessary: Yes
If yes, specify:
No
Signature:Date:
A copy of this form is to be maintained in the patient's record. The original is to be forwarded with this invoice for services rendered to:
Illinois Department of Healthcare and Family Services P.O. Box 19118 Springfield, IL
If additional services are indicated, you will receive another authorization to provide these services.
HFS 1662