Get Hfs 1413 Pdf - State Of Illinois - Www2 Illinois

This guide provides comprehensive instructions on completing the HFS 1413 Pdf, which serves as an agreement for participation in the Illinois Medical Assistance Program. Users will find step-by-step guidance to ensure a smooth and accurate submission process.

Follow the steps to effectively complete the form.

1. Click the ‘Get Form’ button to access the HFS 1413 Pdf. This will allow you to open the document in the online editor for completion.
2. Start by filling in the provider's full legal name in the designated field. If applicable, include the 'doing business as' name.
3. Enter the effective date of the agreement clearly in the provided section, confirming when the services rendered under this agreement commence.
4. Provide any required documentation numbers such as the National Provider Identifier (NPI), if applicable, in the appropriate fields.
5. Review and confirm your compliance with applicable Federal and State laws, regulations, and requirements as outlined in the agreement.
6. Make sure to fill out all relevant sections, ensuring that each statement is accurate and truthful, especially those concerning service compliance and previous ownership interests.
7. If required, include acknowledgment of understanding the consequences of providing false information, which may result in termination from the program.
8. Sign the document where indicated, and include the title of the authorized representative if applicable. Ensure the date of the signature is marked accurately.
9. Upon completing the form, review all entries for correctness. You can then save your changes, download, print, or share the completed form as needed.

Complete the HFS 1413 Pdf online to ensure your participation in the Illinois Medical Assistance Program.