Form HFS 1409 at a glance
What it is: HFS 1409 (R-11-15) is the Prior Approval Request Form of the Illinois Department of Healthcare and Family Services.
Who signs: Box 22 is Approving Authority Signature. In box 23, Provider Signature Date, sign and write the date.
A filled-in Form HFS 1409 example: a provider asks for prior approval
How to fill out Form HFS 1409, box by box
Recipient Name, Birthdate, Provider NPI and Provider Telephone
Enter 1. Recipient #, 2. Recipient Name and 3. Birthdate.
Enter 4. Provider /NPI # and 5. Provider Telephone #.
Provider and Physician Name, Street Address, City, State and Zip Code
Enter 6. Provider Name and 7. Physician Name.
Enter 8. Provider Street Address and 9. Physician Street Address.
Enter 10. Provider City, State and Zip Code, and 11. Physician City, State and Zip Code.
Diagnosis Code, Additional Diagnosis, Diagnosis Description and Patient Height / Weight
Enter 12. Diagnosis Code and 13. Additional Diagnosis.
Enter 14. Diagnosis Description and 15. Patient Height / Weight.
Procedure Code, Description, Qty, Cat. Serv, Begin Date and End Date
Each of boxes 16, 17, 18, 19 and 20 has Procedure Code, Description, Qty, Cat. Serv, Prov Charge, Approved HFS Amt, Begin Date, End Date, Pur/Rent and Mod.
Additional Medical Necessity
Enter 21. Additional Medical Necessity.
Approving Authority Signature and Provider Signature Date
The form certifies that the information is true, accurate, and complete.
Box 22 is Approving Authority Signature.
In box 23, Provider Signature Date, sign and write the date.
Sources
[1] Form HFS 1409 (R-11-15), Prior Approval Request Form, Illinois Department of Healthcare and Family Services (the Official source link on this page).