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IL Provider Forms & Documents
This page is a repository of forms listed by function. The information is intended for use by Providers only. Documents related to Member Services are included for reference. If you have questions, please contact Customer Service at (800) 504-2766 (Medicaid).
Administrative Review
- Appointment of Representative Statement
- Member Appeal Request Form
- Member Grievance Form
- PCP Request for Transfer of Member
- Provider Appeal Request Form
- Provider Complaint Request Form
Authorizations
- Abortion Payment Application (HFS 2390)
- Abortion Payment Application - Spanish (HFS 2390S)
- Authorization/Referral Form
- Hysterectomy Form Patient Acknowledgment (HRS 1977)
- Informed Consent for Voluntary Sterilization (HFS 2189)
- Informed Consent for Voluntary Sterilization - Spanish (HFS 2189S)
- OB Notification Form
Claims
- CMS 1500 Submission Guidelines for Paper Claiims
- CMS 1500 Submission Sample
- UB-04 Submission Guidelines for Paper Claims
- UB-04 Submission Sample
- How to Check the Status of a Claim Online
Medical Records
Pharmacy Services
Provider Job Aids
- How to Become a Registered Web User
- How to Submit an Outpatient Authorization Request Online
- Provider Self-Service Options
- Registering for EFT / ERA Services
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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