Forms

Valuable Links

Healthcare & Family Services (Public Aid) Websites                                         

ILLINOIS:  http://www.hfs.illinois.gov/enrollment/

WISCONSIN: http://www.forwardhealth.wi.gov

INDIANA:  http://provider.indianamedicaid.com/general-provider-services/forms.aspx

 

ADOBE READER: http://get.adobe.com/reader/



Physician providers NOT enrolled for Illinois Public Aid/Medicaid         

Required forms:

2243 -- http://www.hfs.illinois.gov/assets/hfs2243.pdf

1413 -- http://www.hfs.illinois.gov/assets/hfs1413.pdf

1513 -- http://www.hfs.illinois.gov/assets/hfs1513.pdf

2306 -- http://www.hfs.illinois.gov/assets/hfs2306.pdf

2307 -- http://www.hfs.illinois.gov/assets/hfs2307.pdf

W9   -- http://www.irs.gov/pub/irs-pdf/fw9.pdf

Copy of license



Providers enrolled as an Illinois Medicaid provider

Required forms:

2306 -- http://www.hfs.illinois.gov/assets/hfs2306.pdf

2307 -- http://www.hfs.illinois.gov/assets/hfs2307.pdf 

W9   -- http://www.irs.gov/pub/irs-pdf/fw9.pdf

 



Illinois Medicare Part B Website

http://www.ngsmedicare.com/ngs/portal/ngsmedicare/welcome

 



NEW Medicare Part B Illinois providers in solo practice  

Required Forms:

855I  -- https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855i.pdf

588   -- https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS588.pdf

 



NEW Medicare Part B Illinois providers joining existing group practices 

Required Forms:

855I -- https://www.cms.gov/Medicare/CMS-FoS-Forms/downloads/cms855i.pdf

855R -- https://www.cms.gov/Medicare/CMrms/CMS-Forms/CMS-Forms/downloads/cms855r.pdf

 



Current Medicare Part B Illinois providers joining a group

Required Form:

855R -- https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855r.pdf

 

AA051339

 

Phone:  708.452.1111, ext 11

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