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!
Question | Answer |
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Form Name | Hfs 3411C Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | hfs3411c hfs 3411c n 3 06 form |
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 |
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License Number |
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City |
State |
Zip Code |
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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
Physician
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
Phone
Certification
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 |
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Date |
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Please mail your original signed copy to: Healthcare & Family Services |
For more information, |
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Provider Participation Unit |
call: (217) |
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P. O. Box 19114 |
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Springfield, Illinois |
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HFS 3411C