Get Il Hfs 2390 2005-2025
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How to fill out the IL HFS 2390 online
The IL HFS 2390 form is an important document for the Abortion Payment Application, used by healthcare providers to apply for medical assistance payment for abortion services. This guide provides a clear and supportive approach to help users navigate the online filling process with confidence.
Follow the steps to complete the IL HFS 2390 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the recipient's first and last name in the 'Recipient Name' field.
- Fill in the recipient’s complete address in the 'Recipient Address' section.
- Provide the recipient’s case identification number in the 'Case Identification No.' field.
- Enter the recipient's identification number in the 'Recipient Identification No.' field, ensuring it matches the number on the invoice.
- Specify the location where the abortion was performed by including the facility name and address in the 'Location' section.
- Document the date on which the abortion service was performed in the 'Date' field.
- Circle the appropriate code to indicate the reason for the abortion in the 'Abortion Reason' section.
- Print the full name of the physician performing the abortion in the 'Physician performing abortion' section.
- Enter the Medicaid provider number or state license number of the physician in the 'Medicaid Provider Number' field.
- Fill out the street address, city, state, and zip code for the provider's office in the designated fields.
- Require an original signature from the physician performing the abortion in the 'Signature of physician performing abortion' section.
- Include the date when the physician signs the application in the 'Date' field.
- Review the completed form for accuracy and clarity, then save your changes or options to download, print, or share the form as needed.
Start filling out the IL HFS 2390 online today to ensure timely processing of your application.
Related links form
To obtain an Illinois Secretary of State identification number, you need to apply through their official website or visit a local office. The process typically requires you to fill out certain forms and provide identification documents. This number can be important for various purposes, including participating in the IL HFS 2390 program for Medicaid. Ensure you have all required documentation to streamline your application process.
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