Notice of Privacy Incident
Medicaid Provider Termination Alert: Revalidation deadlines are approaching. Failure by providers to revalidate will lead to termination and payment suspension. Check your account now at https://impact.illinois.gov/ to learn if your required revalidation is due this month. More revalidation information here.

Online Application Request

State Chronic Renal Disease Program Application may be requested by completing the following information.

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First Name

Last Name

Street Address

City

State

ZIP

Phone

E-mail Address

Request

E-mail Application

Mail Application

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