The Illinois HFS 2243 form is a crucial document used for provider enrollment in the Illinois Medical Assistance Program. This application is essential for healthcare providers looking to participate in Medicaid services, ensuring they meet all necessary requirements. Completing this form accurately is vital, as any incomplete fields may lead to delays or rejection of the application.
If you’re ready to fill out the Illinois HFS 2243 form, click the button below.
The Illinois HFS 2243 form plays a crucial role in the enrollment process for healthcare providers wishing to participate in the Illinois Medical Assistance Program. This comprehensive application requires providers to provide a range of information, including their name, type, and contact details. It is essential that all fields are filled out accurately; incomplete applications may be returned, causing delays in enrollment. The form includes sections for service specialties, former participation details, and additional National Provider Identification numbers. Providers must also disclose their fiscal information and certifications, ensuring compliance with federal and state laws. Moreover, the form emphasizes the importance of honesty, as any false information could lead to serious consequences, including denial of participation. Understanding the nuances of the HFS 2243 is vital for providers navigating the complexities of healthcare enrollment in Illinois.
Illinois Department of Financial and Professional Regulation - Insurance policies must be comprehensive for adequate protection.
In Florida, establishing a Power of Attorney is crucial for ensuring that someone can make important decisions on your behalf when you are unable to do so. This legal document grants the authority to another individual, which can be essential in protecting your financial and legal interests during times of incapacity. For detailed guidance on crafting a Power of Attorney form specific to Florida, consider visiting TopTemplates.info.
Drivers Test Illinois - Conditions that warrant monitoring are to be noted explicitly by the vision specialist.
Understanding the Illinois HFS 2243 form is crucial for healthcare providers seeking to enroll in the Illinois Medical Assistance Program. However, several misconceptions can lead to confusion. Here are four common misconceptions:
This is not true. All fields in the HFS 2243 form must be completed. If a particular field does not apply, the applicant should write "NONE." Submitting an incomplete application may result in delays or rejection.
In fact, the HFS 2243 form is for various purposes, including re-enrollment and name changes. Existing providers may need to complete the form to update their information or reinstate their participation in the program.
Using a highlighter on the HFS 2243 form is discouraged. It can obscure important information and lead to processing issues. It's best to type or print legibly without any highlighting.
Submitting the HFS 2243 form does not guarantee that a provider will be approved for participation in the Medical Assistance Program. The application will be reviewed, and compliance with federal and state laws is necessary for approval.
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
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
28. Pharmacist
27.
Pharmacy
29.
License #
Location
In Charge
30.
Electronic Billing? 31. If Yes, Pharmacy
32. Pharmacy
Yes
No
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
40. Former Provider Number
Effective Date
Former Provider Name
SECTION D: ADDITIONAL NPI - National Provider Identification #
41. NPI
NPI
SECTION E: PAYEE INFORMATION
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#
Name
DBA
Street Address
Telephone:
City
State
Zip Code
SSN/FEIN
Billing Provider/Pay To NPI #
Medicare Part B#
PIN
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/
Illinois HFS Handbook updates are available: http://www.hfs.illinois.gov/handbooks
Illinois HFS Laws and Rule Regulations: http://www.hfs.illinois.gov/lawsrules/index.html
Signature:
Printed name of person signing above
Check this box if you want a provider handbook mailed
Date
Page 2 of 2
When filling out the Illinois HFS 2243 form, it is important to follow specific guidelines to ensure the application is processed smoothly. Here are four things to do and not to do:
Completing the Illinois HFS 2243 form requires careful attention to detail. Each section must be filled out accurately to ensure the application is processed without delays. Follow the steps below to successfully complete the form.
After completing the form, ensure all sections are filled out correctly. Double-check for any missing information before submitting it to the Illinois Department of Healthcare and Family Services. This will help prevent delays in processing your application.