To obtain the necessary medical necessity forms for durable medical equipment (DME) purchases and rentals in Illinois, particularly for wheelchairs and other equipment, the Illinois Department of Healthcare and Family Services (HFS) provides specific forms and guidelines.
Please download and complete the required forms listed below to initiate your request.
Hospital Bed
Wound Vac
Wheelchairs (Manual, Power, and Custom)
- HFS 3701K – Power Mobility Devices and Custom Manual Wheelchairs Physician’s Form Required for physicians to document the medical necessity for power mobility devices and custom manual wheelchairs.
- HFS 3701H – Seating/Mobility Evaluation Completed by a licensed physical or occupational therapist to support the need for mobility equipment.
- HFS 3701L – Standard Manual Wheelchair Questionnaire Used to assess the necessity for standard manual wheelchairs.
Other Durable Medical Equipment (DME)
- Air Fluidized Bed Questionnaire
- Certificate of Medical Necessity for External Insulin Infusion Pump
- HFS 1409 – Prior Approval Request Form Used to request prior approval for various DME items, including purchases and rentals.
- HFS 1409i – Instructions for HFS 1409 Provides guidance on accurately completing the HFS 1409 form.
- C-PAP/BiPAP Renewal Questionnaire (HFS 3701F) Questionnaire for C-PAP/BiPAP renewal requests.
- TENS Unit Questionnaire (HFS 3701E) Required for TENS Unit medical necessity approval.
- HFS Medical Forms A comprehensive list of DME-related forms.
Additional Resources
Submission Instructions
Fax Numbers:
New Requests: 217-524-0099
Reviews/Specials: 217-558-4359
Mailing Address:
Illinois Department of Healthcare and Family Services
Bureau of Professional and Ancillary Services
P.O. Box 19124
Springfield, IL 62794-9124
For assistance, contact the HFS Prior Approval Unit: 1-877-782-5565
If you need help completing any of these forms or have questions about specific equipment, feel free to ask!