Provider Information
Please limit the quantity of forms and envelopes requested to an amount that would be used in a 3-month period.
Please fill out this field.
Please enter your complete Illinois Medicaid assigned number.
Cannot deliver to Post Office Box
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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
Additional Forms Needed, Not Listed Above
Please provide the Form Number and the Quanity Requested.