The 40 Illinois forms clinicians complete, from school health exams and driver reports to Medicaid prior approval, POLST and medical cannabis certifications.
This page lists the Illinois forms clinicians complete, grouped by program, and each group links to its program hub. School forms reach the most offices: the IDPH Certificate of Child Health Examination for kindergarten, grades 6 and 9 and child care, plus the dental and eye exam reports. The Secretary of State uses the DSD DC 163 medical report for conditions that may impair driving and VSD 62 for parking placards. Medicaid fee-for-service prior approval runs on HFS 1409, and pharmacy requests on HFS 1409X.
Illinois workers' comp has no state form for clinicians: the Section 8.1b impairment rating and the Section 12 exam are narrative reports. Commercial insurers must accept Form 3643 for drug prior authorization. Medical cannabis certifications for adults, minors and the Opioid Alternative Patient Program are created in the IDPH provider portal, not on paper. When a PA or APRN signs VSD 62, a collaborating physician signs too. Of these forms, 8 have a Spanish version, including the POLST. Vero Documents fills PDF forms from the visit note and the chart.
Physician's written impairment rating for permanent partial disability using the current AMA Guides, with measurements such as loss of range of motion, strength and measured atrophy; one of five factors the Commission weighs.
Report of an employer-requested independent medical examination of the injured worker under Section 12 of the Workers' Compensation Act.
Certifying physician's statement of diagnosis, treatment dates and dates of disability for an IMRF member's temporary or total and permanent disability benefit claim.
Provider's report on cardiovascular, neurological, seizure, diabetic, psychiatric and other conditions and whether the person can safely operate a motor vehicle, for Secretary of State medical review.
DSD X 20Eye specialist's report of acuity (incl. telescopic/bioptic readings) and visual fields for an applicant who failed the Secretary of State vision screening.
Medical examination (history, vitals, vision, hearing, urinalysis, systems review) and drug-test documentation required for an Illinois school bus driver permit.
Professional verification of a disability so a person under 65 gets the Reduced Fare Permit for CTA, Metra and Pace in northeastern Illinois.
Medical certification for a temporary, permanent or meter-exempt disability parking placard (and renewal for disability plate holders).
HFS 1409General Illinois Medicaid fee-for-service prior approval request for medical equipment, supplies and other services requiring prior approval.
Uniform pharmacy (and physician-administered drug) prior authorization request accepted by Illinois Medicaid fee-for-service and every HealthChoice Illinois MCO/PBM.
HFS 3701HSeating and mobility evaluation that serves as the letter of medical necessity for power mobility devices and custom wheelchairs.
HFS 3701TPrior approval request for physical, occupational and speech therapy under Illinois Medicaid fee-for-service.
HFS 3082Fee-for-service request for prior approval of a drug.
Certificado de Examen de Salud Infantil
Documents the required school/child care health examination (history, physical, immunizations, lead, diabetes and TB risk, developmental/social-emotional screening) for Illinois school entry, grades K, 6 and 9, and child care enrollment.
Proves the dental examination required for children in kindergarten and grades 2, 6 and 9 (77 Ill. Adm. Code 665), with oral health status and treatment needs.
Proves the eye examination required for children enrolling in an Illinois school for the first time (kindergarten or first entry), due by October 15.
Pre-employment and periodic medical report (TB test, immunization status, findings and fitness) for staff, volunteers and household members in DCFS-licensed child care.
IDPH V-4Eye doctor's report back to the school after a child is referred from the state vision screening program.
Physical examination and clearance required (by IHSA By-law 2.200) before a student participates in IHSA interscholastic athletics.
Written clearance from a licensed provider plus parent consent for a student to enter and complete the school's Return-to-Play and Return-to-Learn protocols after a concussion (Illinois Youth Sports Concussion Safety Act).
Religious exemption from school immunizations and/or health, dental or eye examinations, which must carry the signature of the child's health care provider after the provider informs the family of the benefits and risks.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Formulario de Órdenes del Médico para el Tratamiento de Soporte Vital (POLST) del IDPH
Portable medical order recording CPR/DNR, scope of treatment and artificial nutrition decisions for patients with serious life-limiting illness or frailty; also serves as Illinois' out-of-hospital DNR.
Petition asserting that a person is subject to emergency involuntary or judicial inpatient admission, filed with the circuit court together with examiners' certificates.
IL462-2006Examiner's certificate that a person is subject to involuntary or judicial inpatient admission (and whether immediate hospitalization is needed), supporting the petition in circuit court.
Health care professional certifies an adult patient's debilitating medical condition (including terminal illness or lifelong condition) for a medical cannabis registry card.
Two health care professionals certify a minor patient's debilitating condition: one recommending, one reviewing, with identical qualifying conditions.
Physician certifies that a patient 21+ has a condition for which an opioid has been or could be prescribed, allowing medical cannabis as an alternative.
Secure web-based case report of suspected or confirmed reportable infectious diseases (demographic, medical and exposure information), routed to the local health department.
Non-emergency online report of suspected child abuse or neglect to the DCFS Child Abuse and Neglect Hotline.
IOCI 25-1279Reports a blood lead test result (patient, test, provider and lab details) to the Illinois Lead Program.
Physician, PA or licensed practitioner certifies that a resident's medical condition would be aggravated by loss of electric service, stopping disconnection for 60 days (once per 12 months; 83 Ill. Adm. Code 280.160).
Knowledgeable professional certifies a public housing or voucher household member's disability and the disability-related need for each requested accommodation; CHA decides within about 30 days.
Application for state-funded amplified, captioned, TTY or cell phone equipment; page 2 is signed by a doctor or other certifier confirming the applicant is deaf, hard of hearing, late-deafened, speech disabled or deaf-blind and cannot use a standard phone.
Clinician certifies, using Social Security Administration disability criteria, that a homeowner is disabled so the county can grant the Homestead Exemption for Persons with Disabilities (HEPD) when no SSA letter or Class 2 disability ID is available.
Licensed physician's sworn statement that a hunter is paraplegic or permanently/temporarily disabled (mobility aids, lung disease, cardiac class III/IV, etc.) for a permit to hunt from a standing vehicle.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The physician, APRN or PA who performs the exam. The provider completes pages 2 and 3: the physical exam, screenings, immunization verification and signature. The parent fills in the health history on page 1. Exams done after January 1, 2025 must use the updated form, which adds social-emotional and developmental screening. The parent gives the form to the school or child care facility, and a Spanish version is available.
A licensed medical professional completes Part 3 of VSD 62, and Part 4 for meter-exempt eligibility. A PA, APRN or resident must add a collaborating or supervising physician's signature. The form asks for a state professional license number, not an NPI. A temporary certification is valid 6 months from the signature and a permanent one 4 years. Third-trimester pregnancy qualifies for up to 90 days.
Yes. IDPH publishes the Uniform POLST form in Spanish, Arabic, Chinese, French, Hindi, Korean and Polish. The attending physician, APRN, PA or resident signs the Section A to C orders with the patient or legal representative. The original stays with the patient, and copies, faxes and electronic versions are valid. The form also serves as the Illinois out-of-hospital DNR and can be printed on any color paper.
A licensed physician, physician assistant or licensed practitioner completes ComEd's Request for Medical Certification, stating that loss of electric service would aggravate the resident's condition. No diagnosis is required. The certification stops disconnection for 60 days, once per 12 months. The form can be faxed or uploaded on ComEd's website, and the customer must contact ComEd within 14 days of a service interruption. It is also available in Spanish.