Fill a Valid Illinois Hfs 2243 Form

The Illinois HFS 2243 form is a Provider Enrollment Application for the Illinois Medical Assistance Program. This form is essential for healthcare providers seeking to enroll, re-enroll, or make changes to their status within the program. Completing this application accurately is crucial, as any incomplete fields may result in delays or rejection.

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Table of Contents

The Illinois HFS 2243 form is a crucial document for healthcare providers seeking enrollment in the Illinois Medical Assistance Program. This application requires careful attention to detail, as all fields must be completed accurately to avoid delays or rejections. The form covers various aspects of provider information, including the type of enrollment—whether it is a new enrollment, re-enrollment, name change, or reinstatement request. Essential details such as the provider's name, address, National Provider Identification (NPI) number, and contact information must be provided. Additionally, the form includes sections that address service categories and specialties, allowing providers to specify their primary and secondary specialties. For physicians, specific qualifications and hospital admitting privileges are also required. The form further necessitates the disclosure of any prior participation in the program, and it includes a certification section where the provider affirms the accuracy of the information submitted. Compliance with federal and state laws is emphasized, ensuring that all applicants are aware of the legal implications of providing false information. By completing the HFS 2243 form, healthcare providers can take a significant step toward participating in a program that supports access to medical services for those in need.

Example - Illinois Hfs 2243 Form

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/

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

HFS 2243 (R-7-09)

Page 2 of 2

▼ PDF

Document Breakdown

Fact Name	Details
Form Purpose	The HFS 2243 form is used for provider enrollment in the Illinois Medical Assistance Program.
Eligibility	Providers must complete all fields; incomplete applications may be returned.
Non-Applicable Fields	If a field does not apply, the applicant should indicate "NONE" in that section.
Sections	The form consists of multiple sections, including Provider Information, Service/Specialty, and Certification/Signature.
Provider Types	Options include new enrollment, re-enrollment, name change, and reinstatement requests.
Governing Laws	This form is governed by the Illinois Compiled Statutes, specifically under healthcare regulations.
Electronic Billing	Providers can indicate if they will use electronic billing, which is an option on the form.
Certification Requirement	Applicants must certify that all information is true and that they comply with federal and state laws.
Verification Authorization	By signing, applicants authorize the Department of Healthcare and Family Services to verify provided information.

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