Get Provisional Provider Authorization Request - Illinois Department Of ... - Dhs State Il

This guide provides clear and detailed instructions on how to successfully fill out the Provisional Provider Authorization Request form for the Illinois Department of Human Services. Whether you are a provider or a service coordinator, following these steps will help ensure your submission is complete and accurate.

Follow the steps to complete the authorization request form effectively.

1. Click ‘Get Form’ button to access the Provisional Provider Authorization Request form and open it for completion.
2. Fill out Section 1, Family Information. Provide the child's name, address, and parent/guardian's information, including their daytime phone number and EI/CBO number.
3. In Section 2, Non-Enrolled Service Provider Information and Certification, enter the provider's name, address, and phone number. Indicate whether the provider is in the process of enrolling with the CBO and if they are currently enrolled but not an evaluator. Attach any required documentation, such as a qualifying license or certification.
4. Ensure the provider completes the certification statement acknowledging the provision of Early Intervention services and the requirement of provisional authorization from DHS. Include their signature and the date.
5. Complete the details for the service needed, including discipline, location, authorization dates, and number of required sessions. Indicate the names of any enrolled EI providers contacted and the reasons for their unavailability.
6. Have the service coordinator and CFC manager sign and date the respective sections to validate the request.
7. After verifying that all sections are complete and all attachments are included, submit the form and accompanying documents to the Department of Human Services for review.

Start filling out your Provisional Provider Authorization Request form online today to ensure timely processing.