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Possible online services disruption due to Internet related outage

A worldwide technology outage is causing disruption to some State of Illinois online systems.  We are aware of this issue and are diligently working on restoration.

Elizabeth M. Whitehorn, Director

Paper Medical Forms Request

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

* indicates required field

Provider Information

Please limit the quantity of forms and envelopes requested to an amount that would be used in a 3-month period.

Please enter your complete Illinois Medicaid assigned number.

Cannot deliver to Post Office Box

Do not use punctuation in this field.

HFS Form Number and Quantity Requested

Drug Invoice, (Continuous Feed Format)

Prior Approval Request

Provider Invoice, (Single Sheet)

Provider Invoice, (Continuous Feed Format)

Transportation Invoice, (Single Sheet)

Transportation Invoice, (Continuous Feed Format)

Medical Equipment / Supplies Invoice, (Single Sheet)

Medical Equipment / Supplies Invoice, (Continuous Feed Format)

Laboratory / Portable X-Ray Invoice, (Single Sheet)

Laboratory / Portable X-Ray Invoice, (Continuous Feed Format)

Health Agency Invoice, (Single Sheet)

Health Agency Invoice, (Continuous Feed Format)

Health Insurance Claim Form, (Single Sheet)

Health Insurance Claim Form, (Continuous Feed Format)

Medicare Crossover Invoice (Single Sheet)

Medicare Crossover Invoice (Continuous Feed Format)

HFS Envelope Number and Quantity Requested

Medicare Crossover

Special Approval

Drug Invoice

Adjustments

Provider Invoice

Transportation Invoice

Health Agency Invoice

Medical Equipment Supplies

NIPS Special Invoice Handling

Equip/Supplies Prior Approval

Prior Approval Request

Additional Forms Needed, Not Listed Above

Please provide the Form Number and the Quanity Requested.