Form Hfs 1662 PDF Details

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!

Form NameForm Hfs 1662
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other nameshfs1662 state of illinois primary care provider authorization form

Form Preview Example

State of Illinois

Department of Healthcare and Family Services


(Non-Emergency Services Only)

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:


Recipient Number:

Referred Provider Name:

Referred Provider Address:

Reason for Referral:

Date of Appointment:



month / day / year



Primary Care Physician






or Pharmacy Signature

Date Medication Prescribed:




Date of Referral:









month / day / year






Section B: To be completed by the referred provider


Treatment/Medication/Goods Dispensed:

Additional Treatment Necessary: Yes

If yes, specify:



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 62794-9118

If additional services are indicated, you will receive another authorization to provide these services.

HFS 1662 (R-5-14)