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


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.