Form Hfs 2316 PDF Details

The Form HFS 2316 is used to request an inspection of records by the California Department of Health Care Services. The form must be completed and submitted by the person who is requesting the inspection, and can be used to request records from any provider that participates in the Medi-Cal program. Records requested through this form may include claims history, provider information, or other data related to the recipient's care. The department will typically respond within 30 days of receiving the request.

QuestionAnswer
Form NameForm Hfs 2316
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshfs2316 hfs2316 form

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State of Illinois

Department of Healthcare and Family Services

LIMITED POWER OF ATTORNEY

I,

, do hereby make and appoint

 

Name of Facility's Administrator (Printed)

 

Name of Agent

as my true and lawful attorney in fact for me and in my name solely for the purpose of signing the Billing Certification located on the last page of Form HFS 194-M-1, Remittance Advice, and Form HFS 2234, Bed Reserve Form.

The agent is employed at the facility and will, before signing Form HFS 194-M-1, assure the accuracy of the payment received.

This limited power of attorney shall remain in effect until such time as the Illinois Department of Healthcare and Family Services is notified in writing that it has been revoked.

This authorization in no way limits the facility's or my rights, liabilities or duties relating to the provisions of service under the Illinois Department of Healthcare and Family Services Medical Assistance Program. I accept full responsibility for all payments received from the Illinois Department of Healthcare and Family Services under my name on Form HFS 194-M-1 and Form HFS 2234.

Name of Facility

Address of Facility

 

 

 

 

 

Signature of Facility Administrator

 

Date

 

 

 

 

 

Date

Signature of Agent

 

 

 

 

Printed Name of Agent

 

 

HFS 2316 ( R-11-09)

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1. Start filling out the Form Hfs 2316 with a group of major blanks. Get all the required information and ensure there's nothing left out!

Writing section 1 of Form Hfs 2316

2. The subsequent stage is to complete these particular blank fields: Address of Facility, Signature of Facility Administrator, Signature of Agent, Printed Name of Agent, Date, and Date.

Date, Signature of Facility Administrator, and Printed Name of Agent in Form Hfs 2316

Always be extremely attentive when completing Date and Signature of Facility Administrator, as this is the part in which many people make a few mistakes.

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