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Page Content
NOTE:
Providers have the option to bill the Department electronically, which is the Department’s preferred method for claim submission.
Although paper claim forms are available, the Department strongly encourages providers to utilize the
Medical Electronic Data Interchange Internet Electronic Claims (MEDI IEC) System
to submit claims, as well as to
verify eligibility, view claims status, download remittance advices, and access other HFS information online through a web interface
.
The Department also encourages providers to utilize the electronic forms repository on the
HFS Forms webpage
.
These forms are in a PDF-fillable format unless otherwise indicated. These forms may be completed online, printed, and mailed to the appropriate area of the Department. Certain claim forms are specifically identified as “Example Only” and cannot be completed and mailed to the Department.
If ordering paper forms, please limit the quantity of forms and envelopes requested to an amount that would be used in a 3-month period.
Enter the quantity of the forms being requested.
When ordering your 3 month supply, please be sure to indicate the total number of individual forms or envelopes needed in the Quantity column, not the number of boxes, cases or packages.
Please verify you have entered accurate information in the required fields.
Forms and Envelopes Out of Stock
The following Forms/Envelopes are currently out of stock. If you are ordering these items expect a delay in processing this portion of your request. Please do not reorder out of stock items. Backorders will be automatically filled when stock is available.
Envelope 2244
Electronic Format Only
No longer available in the warehouse:
HFS 2292
HFS 1409
Provider Name
Provider Number
Please enter your complete Illinois Medicaid assigned number.
Street Address
Cannot deliver to Post Office Box
City
State
ZIP
Attention
Phone
Do not use punctuation in this field.
E-mail Address
HFS 215CF
Drug Invoice, (Continuous Feed Format)
HFS 1409
Prior Approval Request
HFS 1443
Provider Invoice, (Single Sheet)
HFS 1443CF
Provider Invoice, (Continuous Feed Format)
HFS 2209
Transportation Invoice, (Single Sheet)
HFS 2209CF
Transportation Invoice, (Continuous Feed Format)
HFS 2210
Medical Equipment / Supplies Invoice, (Single Sheet)
HFS 2210CF
Medical Equipment / Supplies Invoice, (Continuous Feed Format)
HFS 2211
Laboratory / Portable X-Ray Invoice, (Single Sheet)
HFS 2211CF
Laboratory / Portable X-Ray Invoice, (Continuous Feed Format)
HFS 2212
Health Agency Invoice, (Single Sheet)
HFS 2212CF
Health Agency Invoice, (Continuous Feed Format)
HFS 2360
Health Insurance Claim Form, (Single Sheet)
HFS 2360CF
Health Insurance Claim Form, (Continuous Feed Format)
HFS 3797
Medicare Crossover Invoice (Single Sheet)
HFS 3797CF
Medicare Crossover Invoice (Continuous Feed Format)
HFS 824MCR
Medicare Crossover
HFS 1414
Special Approval
HFS 1415
Drug Invoice
HFS 1416
Adjustments
HFS 1444
Provider Invoice
HFS 2244
Transportation Invoice
HFS 2246
Health Agency Invoice
HFS 2247
Medical Equipment Supplies
HFS 2248
NIPS Special Invoice Handling
HFS 2294
Equip/Supplies Prior Approval
HFS 2300
Prior Approval Request
HFS Form Number
Quantity
Leave Blank
Medical Forms Request
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