Are you an employer who is looking to hire a new employee? If so, you will need to complete Form Hfs 1662, which is known as the Employers Request for Approval of Job Placement. This form must be submitted to the Department of Human Services before you can advertise or interview any potential employees. In this blog post, we will go over what information is required on Form Hfs 1662, and we will also provide a downloadable PDF version of the form. Let's get started!
Question | Answer |
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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 |
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