Get Illinois Health Connect Provider Referral Fax Form

The Illinois Health Connect Provider Referral Fax Form is crucial for healthcare providers to facilitate proper patient referrals. This guide provides clear, step-by-step instructions to help you fill out this form efficiently and accurately when completing it online.

Follow the steps to complete the referral form effectively.

1. Press the ‘Get Form’ button to access the referral fax form and open it in your online document editor.
2. Fill in the required referring provider information, which includes the provider’s first name, last name, HFS number, location name or IHC site number, address, city, state, name of the person completing the form, contact phone, return fax number, authorizing signature, and date.
3. Complete the client information section by providing the client's first name, last name, HFS recipient ID number, and date of birth.
4. In the rendering provider information section, enter the rendering provider’s first name, last name, HFS number, location name, address, city, state, and contact phone number.
5. Identify the referral time span by entering the begin and end dates. Ensure that these dates are tailored to the urgency of the referral.
6. Optionally, use the ‘Reason for Referral/Diagnosis’ section to include any pertinent details about the patient’s care. However, maintain confidentiality by sharing sensitive information through secure communication.
7. Once all sections are complete, review the information for accuracy. Save the changes, and choose to download, print, or share the form as needed.

Start filling out your Illinois Health Connect Provider Referral Fax Form online today!