Illinois Health Connect Provider Referral Fax Form 2026

1. Click ‘Get Form’ to open the Illinois Health Connect Provider Referral Fax Form in the editor.
2. Begin by filling out the 'Referring Provider Information' section. Enter the provider's first and last name, HFS number, location name, address, city, state, and contact phone number. Ensure all fields are completed accurately.
3. Next, provide your return fax number and authorizing signature along with the date to validate the referral.
4. Proceed to the 'Client Information' section. Input the client's first name, last name, HFS recipient ID number, and date of birth.
5. In the 'Rendering Provider Information' section, enter details for the provider receiving the referral including their first and last name, HFS number, location name, address, city, state, and contact phone number.
6. Specify the 'Referral Time Span' by indicating both a start and end date for services. Remember to keep this timeframe appropriate based on patient needs.
7. Optionally include any additional information in the 'Reason for Referral/Diagnosis' section if necessary.
8. Once completed, fax the form to (412) 318-2740 or consider submitting electronically via the Illinois Health Connect Provider Portal for convenience.

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