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Click ‘Get Form’ to open it in the editor.
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.
In the section for payment amount, clearly state the sum you are seeking from the State of Illinois. Be specific about the medical services rendered.
Complete Exhibit 'A' by itemizing each service provided, including patient names, identification numbers, and dates of service. This detailed breakdown is essential for your claim.
Attach any necessary invoices as outlined in Exhibit 'B', ensuring they correspond with the claims listed in Exhibit 'A'.
Review all entries for completeness and accuracy before signing at the bottom of the form. Your signature confirms that you are entitled to payment.

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2016 illinois claims vendors form template

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