Illinois Form Hfs 2243 – Fill Out and Use This PDF

The Illinois HFS 2243 form serves as a provider enrollment application for those wishing to participate in the Illinois Medical Assistance Program. It is an essential document that must be completed thoroughly and legibly, with every field filled out to avoid return of the application. This form collects detailed information about the provider, including their type, primary office address, contact information, and various identifications necessary for enrollment. Take the first step towards becoming an Illinois Medical Assistance Provider by filling out the HFS 2243 form. Click the button below to begin.

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Illinois Form Hfs 2243 PDF Details

The Illinois HFS 2243 form is a comprehensive document designed by the State of Illinois Department of Healthcare and Family Services, serving as a pivotal component for those seeking enrollment or specific changes within the Illinois Medical Assistance Program. This detailed application mandates that all provided information be either typed or printed legibly, with a strict advisory against the use of highlighters on any submitted documents. It underlines the importance of completeness in the application process, stating that any incomplete fields, unless explicitly non-applicable (in which case, "NONE" should be indicated), may result in the return of the application. The form spans several key sections that cover a wide array of information, including provider details, service or specialty offered, previous participation, additional National Provider Identification (NPI) numbers, and payee information, alongside a certification and signature section that emphasizes the veracity and compliance of the provided information. This certification highlights the legal and ethical obligations of the applicants, underscoring the seriousness of the enrollment process and the adherence to federal and state laws and regulations. The HFS 2243 form exemplifies a rigorous process designed to ensure that providers enrolled in the Medical Assistance Program are not only qualified but also committed to maintaining the standards and regulations as stipulated by the Department of Healthcare and Family Services. Furthermore, it serves as a gateway for healthcare providers to participate in a program that is critical to a vast number of Illinois residents, thus playing a significant role in the broader public health ecosystem of the state.

Question	Answer
Form Name	Illinois Form Hfs 2243
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	illinois medicaid provider enrollment, FEIN, SSN, NPI

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State of Illinois

Department of Healthcare and Family Services

PROVIDER ENROLLMENT APPLICATION

ILLINOIS MEDICAL ASSISTANCE PROGRAM

(Must be Typed or Printed Legible and Do Not Use Highlighter On Any Documents.)

All fields must be completed or the application may be returned. If a field is Non-Applicable, the applicant should type or print NONE.

SECTION A: PROVIDER

1.New Enrollment

3.Provider Name

Re-Enrollment

Name Change

Reinstatement Request

2. Provider Type

4.Primary Office Address

5.City

6. County

7.State

8. Zip Code

9. Telephone:

10. Fax:

11.	E-mail Address (3)


12.	National Provider Identification # - NPI


14.	SSN	15.	License/Certification


17.	Medicare	18.	Organization
	Part A#		Type

Report Additional

NPI's In Section D13. FEIN

		16. DEA

19. Control of	20. Fiscal
19. Control of	20. Fiscal
Facility		Year

21. CLIA #

SECTION B: SERVICE/SPECIALTY

22.Category of Service

23.Provider Specialty: Primary Specialty

24.Physician UPIN No.

Secondary

Specialties

25.OBRA Qualifications (Physicians Only)

26. Hospital Admitting Privilege: (Physicians Only)

Hospital Name

Address

Hospital Name

Address

28. Pharmacist

27.

Pharmacy

29.

License #

Location

In Charge

30.

Electronic Billing? 31. If Yes, Pharmacy

32. Pharmacy

Yes

Software Vendor Name

NCPDP#

33.

Transportation: Taxi

34. Taxi

35.

Medicar: Hydraulic

Manual Lift or Ramp Yes

Base/Meter/Flag Rate

Mileage Rate

36.

Long Term Care

37. Long Term Care

Medical Bed Capacity

Medicare Fiscal Intermediary

38.Long Term Care Building ID Code

HFS 2243 (R-7-09)

Page 1 of 2

SECTION C: FORMER PARTICIPATION

39. Change of Ownership

Yes

40. Former Provider Number

Effective Date

Former Provider Name

SECTION D: ADDITIONAL NPI - National Provider Identification #

41. NPI

NPI

SECTION E: PAYEE INFORMATION

NPI

42. Name

44.DBA

45.Street Address

46.City

50.SSN/FEIN

52.Medicare Part B#

43. Telephone:

47. State			48. Zip Code		49. TIN Type Code


		51. Billing Provider/Pay To NPI #
	53. PIN
				54. DMERC#
				54. DMERC#

Name

DBA

Street Address

Telephone:

City

State

Zip Code

SSN/FEIN

Billing Provider/Pay To NPI #

Medicare Part B#

DMERC#

SECTION F: CERTIFICATION/SIGNATURE

TIN Type Code

I understand that knowingly falsifying or willfully withholding information may be cause for the denial or termination of participation in the Medical Assistance Program and such conduct may be prosecuted under applicable Federal and State laws..

Under penalties of perjury, I hereby certify that all of the information provided in this application process is true, correct and complete and that the enrolling provider is in compliance with all applicable federal and state laws and regulations. I further certify that neither I, nor any of the following provider's employees, partners, officers, or shareholders owning at least five percent (5%) of said provider are currently barred, suspended, terminated, voluntarily withdrawn as part of a settlement agreement, or otherwise excluded from participation in the Medicaid or Medicare programs, nor are any of the above currently under sanction for, or serving a sentence for conviction of any Medicaid or Medicare program violations. I further certify that none of the above are currently sanctioned by any federal agency for any reason. I authorize the Department of Healthcare and Family Services, to verify the information provided on this application with other state and federal agencies. I further certify that I will review and comply with the Department's policies, rules and regulations including but not limited to those found at the following websites:

Illinois HFS website address: http://www.hfs.illinois.gov/	Check this box if you want

Illinois HFS Handbook updates are available: http://www.hfs.illinois.gov/handbooks
	a provider handbook mailed
Illinois HFS Laws and Rule Regulations: http://www.hfs.illinois.gov/lawsrules/index.html

Signature:

Date

Printed name of person signing above

HFS 2243 (R-7-09)

Page 2 of 2

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This PDF will require specific information to be filled out, so you must take the time to type in precisely what is expected:

1. For starters, once filling out the DBA, beging with the page that has the next blank fields:

E-mail conclusion process shown (stage 1)

2. Now that the previous segment is finished, it's time to insert the required details in Provider Specialty Primary, Physician UPIN No, Hospital Admitting Privilege, Hospital Name, Hospital Name, Secondary Specialties, OBRA Qualifications Physicians, Address, Address, Pharmacy Location, Pharmacist In Charge, Electronic Billing, Yes, If Yes Pharmacy Software Vendor, and License allowing you to move on further.

E-mail conclusion process detailed (portion 2)

3. The third step is simple - fill out all the fields in Long Term Care Building ID Code, HFS R, and Page of in order to finish this part.

4. To move forward, the following stage involves filling in a handful of empty form fields. Included in these are SECTION C FORMER PARTICIPATION, Change of Ownership, Yes, Former Provider Number, Former Provider Name, SECTION D ADDITIONAL NPI National, NPI, NPI, NPI, NPI, SECTION E PAYEE INFORMATION, Effective Date, NPI, NPI, and Telephone, which are key to carrying on with this process.

5. Since you approach the conclusion of the form, there are actually a few extra requirements that should be satisfied. Particularly, SSNFEIN, Billing ProviderPay To NPI, Medicare Part B, PIN, DMERC, Name, DBA, Street Address, City, SSNFEIN, Telephone, State, Zip Code, TIN Type Code, and Billing ProviderPay To NPI should be filled out.

Tips on how to fill out E-mail portion 5

People frequently make errors when completing Street Address in this area. Be sure to double-check whatever you type in here.

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Illinois Form Hfs 2243 – Fill Out and Use This PDF

Illinois Form Hfs 2243 PDF Details

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