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Illinois Health Connect Provider Referral Fax Form

Illinois Health Connect Provider Referral Fax Form 2025

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4.9 out of 5

39 votes

The document outlines the Illinois Health Connect Provider Referral Fax Form, which is used by primary care providers (PCPs) to authorize referrals to other non-affiliated Illinois Health Connect PCPs. It details the required information for both referring and rendering providers, guidelines for referral time spans, and optional sections for additional patient information. The form must be faxed to the Illinois Health Connect Care Coordination Unit, and it emphasizes the confidentiality of the information contained within.

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Versions	Form popularity	Fillable & printable
2009	4.9 Satisfied (39 Votes)

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