Medical Vendors Form - Illinois Secretary of State 2025

1. Click ‘Get Form’ to open the Medical Vendors Form in our editor.
2. Begin by entering the claimant's name and contact information in the designated fields. Ensure accuracy as this information is crucial for processing your claim.
3. In the section regarding payment sought, specify the total amount requested and provide a brief description of the medical services rendered.
4. Attach Exhibit 'A' detailing each service provided, including recipient identification numbers and case details. Use our platform’s upload feature to easily attach these documents.
5. Indicate whether payment was disallowed by checking the appropriate box and providing any necessary documentation as Exhibit 'C'.
6. Finally, review all entered information for accuracy before signing electronically using our editor’s signature feature.

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