Hfs 3411C Form PDF Details

Are you looking to get your hands on one of the most commonly used free forms in the U.S. tax system? If so, then you may need Hfs 3411C form. This form is an important component for taxpayers when filing their federal and state income taxes, as it allows them to document the income they received throughout the year. In this blog post, we’ll explore what kind of information needs to be included on Hfs 3411C form and answer other frequently asked questions about using it. Keep reading to learn more!

Form NameHfs 3411C Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other nameshfs3411c hfs 3411c n 3 06 form

Form Preview Example

State of Illinois

Department of Healthcare and Family Services

Advance Practice Nurse (APN) Certification and

Collaborative Agreement Form

Provider Information

Last Name, First Name, Middle Initial

Office Address

Provider Number


License Number







Zip Code





Office Phone

After Hours Phone

Fax Number

APN Certifications Include: (Check all that apply)

Certified Nurse Midwife

Certified Registered Nurse Anesthetist

Certified Nurse Practitioner Specialty(s):

Clinical Nurse Specialist Specialty(s):

Collaborating Physician(s):

Physician Name

Physician Address

Physician FEIN


License Number

State of Licensure

For CRNAs who are not required to maintain a collaborative or written practice agreement, list the following information:

Hospital Name

Street Address/City/State/Zip



I certify that I meet the participation requirements for an Advance Practice Nurse. I also understand that I must notify the Department in writing should any changes to the information contained herein become necessary. I also understand that the information I enter on this form will be used to update the Department's data base.

Provider Signature





Please mail your original signed copy to: Healthcare & Family Services

For more information,


Provider Participation Unit

call: (217) 782-0538


P. O. Box 19114




Springfield, Illinois 62794-9114



HFS 3411C (N-3-06)