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Medical Vendors Form CC-93 - Illinois
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Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 (Complete six 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 Public Aid (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, theamounts invoiced to the Department for such services, the dates and sequ ence of Claimants 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(Claimants Bill of Particulars of the accounts for which Claimant seeks payment) , hereto attached. For each service, person and amount identified in Exhibit A Clai mant has presented claims to the Department by DPA form invoices listed in Exhibit A, copies of which invoices are attached as Exhibit B. For each claim itemized inExhibit 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 Comp laint. Claimant is enrolled as a participant in the Department of Public Aid s Medical Assistance Program, and has complied with the Departments requirements and regulations, as applicable to the subject medical ser vices. Claimant further states that no assignment of said claim, or any part th ereof, or any interest therein, has been made to anyperson, and that Claimant is justly entitled to payment of the same from Respondent after allowing all just credits. Claimant further states that Claimants Federal Employer Identification Number (F.E.I.N.) is: ______________ , or thathis/her Social Security Number is: ______________________________ . _________________________________________Ref: Section 11-13, Chpt. 23, Claimants Signature Ill. Revised Statutes as amended. (Complete Reverse Side) IDPA Medical-Service provider (Vendor) Printed by authority of the State of Illinois - March 2005 - 500 - CC-93 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2STATE OF ___________________________ ) ) COUNTY OF ________________________ ) _____________________________________ being duly sworn, upon oath depose s and says that he/she is the same person who signed the foregoing complaint, that he/she has read the same and kn ows the contents thereof, and that the facts therein set forth are true. ________________________________________________ Claimant ________________________________________________ Street Address ________________________________________________ City State ________________________________________________ ZIP Telephone Number Subscribed and sworn to me this ____________________ day of ____________ _____________ 20 _____ . ______________________________________________ Notary Public ________________________________________________ Claimant s Attorney ________________________________________________ Street Address ________________________________________________ City State ________________________________________________ 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 Printed by authority of the State of Illinois - March 2005 - 500 - CC-93 American LegalNet, Inc. www.USCourtForms.com
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