Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete four copies) Medical Vendors Form IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) ) ) ) ) ) ) Claimant vs. Respondent, STATE OF ILLINOIS Claimant seeks from Respondent payment in the sum of $ ____________________________________________ for ______________________________ rendered by Claimant to persons eligible for Medical Assistance under programs Type Medical Service administered by the Illinois Department of Healthcare and Family Services (hereinafter the Department). The names of said persons, their Recipient identification numbers as assigned by the Department, the Case names and Case identification numbers assigned by the Department to the persons' family units, the dates of the services, which are the subject of this claim, the amounts invoiced to the Department for such services, the dates and sequence of Claimant's invoices to the Department, and the actions of the Department in response to those invoices (and the dates of such actions), are itemized in Exhibit "A" (Claimant's Bill of Particulars of the accounts for which Claimant seeks payment), hereto attached. For each service, person and amount identified in Exhibit "A" Claimant has presented claims to the Department by form invoices listed in Exhibit "A," copies of which invoices are attached as Exhibit "B." For each claim itemized in Exhibit "A" payment was disallowed by the Department: ________ (1) in documents designated by the voucher numbers stated in Exhibit "A," a copy of each such voucher being attached hereto as Exhibit "C," or ________ (2) by other response, as detailed by Claimant in Exhibit "A." Exhibits "A," "B" and "C" are made a part of this Complaint. Claimant is enrolled as a participant in the Department's Medical Assistance Program, and has complied with the Department's requirements and regulations, as applicable to the subject medical services. Claimant further states that no assignment of said claim, or any part thereof, or any interest therein, has been made to any person, and that Claimant is justly entitled to payment of the same from Respondent after allowing all just credits. _________________________________________ Claimant's Signature Ref: Section 11-13, Chpt. 23, Ill. Revised Statutes as amended. IDPA Medical-Service provider (Vendor) Printed by authority of the State of Illinois - December 2016 - 1 - CC 93.2 American LegalNet, Inc. www.FormsWorkFlow.com ________________________________________________ Claimant ________________________________________________ Claimant's Attorney ________________________________________________ Street Address ________________________________________________ Street Address ________________________________________________ City State or ________________________________________________ City State ________________________________________________ ZIP Telephone Number ________________________________________________ ZIP Telephone Number Exhibit A BILL OF PARTICULARS ________________________________________________ Claimant (Provider) Name ________________________________________________ Provider Reference (PR) No. (assigned by Provider) ________________________________________________ Court of Claims Docket No. ________________________________________________ Dates of Service (DOS) ________________________________________________ Patient Name ________________________________________________ Provider Billings & IDPA Responses ________________________________________________ Patient Date of Birth (DOB) ________________________________________________ PR # ________________________________________________ IDPA Recipient No. (RIN) ________________________________________________ DOS ________________________________________________ (IDPA Case Name/Case No.) ________________________________________________ Amount Billed to IDPA American LegalNet, Inc. www.FormsWorkFlow.com