CFS 415: Ordinary and Routine Medical and Dental Care

Please read the instructions below prior to completing the request. Failure to follow instructions may result in a processing delay.

Instructions:
Only submit a request for consent for a current provider(s). Do not submit a request for emergency rooms, or urgent, immediate or convenient care providers. Do not use acronyms anywhere in the request. If you are submitting a request for HIV testing, please read the DCFS risk factors for HIV testing by clicking HERE.

Ordinary and Routine medical and dental care includes, but is not limited to:
1. Physical and dental examinations
2. Remedial treatment for minor illnesses
3. Immunizations and related diagnostics laboratory tests, including HIV testing when risk factors are present

This type of request for consent is NOT valid for the following items. Please call the consent unit hotline Monday - Friday from 8:30am-4:30pm at (800) 828-2179. For after hours / state holidays, call (866) 503-0184:
1. Emergency room
2. Urgent care, prompt care, express care, immediate care
3. Walk in clinic

This type of request for consent is NOT valid for the following items. Please complete a CFS 431 request for these categories:
1. Surgery/Procedure
2. Anesthesia
3. Blood transfusions
4. Tooth extractions
5. DNA Testing
6. Sleep Study

Form Submission

Requestor Information

First Name

Last Name

Please use an Illinois.gov email if possible. The completed consent will be returned to this email.

Phone Number

Please provide a direct phone number, and phone extension if applicable, where the requestor can be reached in case additional information is needed to process the request.

Phone Extension

***

Fax

Office of the Guardian - Consent Unit

Office of the Guardian - Consent Unit