Get Il Dpa 2390 2001-2026

The IL DPA 2390, also known as the Abortion Payment Application, is an essential document for medical professionals seeking payment for abortion services under Medical Assistance. This guide provides a step-by-step approach to filling out the form online, ensuring accuracy and compliance with the requirements.

Follow the steps to complete the Abortion Payment Application effectively.

1. Click the ‘Get Form’ button to access the IL DPA 2390 and open it in your preferred digital editor.
2. Begin by entering the recipient's name in the designated field at the top of the form.
3. Fill in the recipient's address, ensuring to include the street address, city, state, and zip code in the appropriate sections.
4. Locate the case identification number field and provide the relevant number associated with the recipient.
5. Input the recipient identification number in the specified area, ensuring it matches the official documentation.
6. State the location where the abortion was performed by filling out the name of the location and the city where the service took place.
7. Enter the date on which the abortion was performed into the designated space.
8. Select the appropriate code indicating the reason for the abortion by circling one of the provided options: Surgical or .
9. In the designated space, provide a detailed explanation if the abortion was necessary due to a medical condition, indicating the corresponding code.
10. After filling out the necessary fields, have the physician performing the abortion print their name and Medicaid provider number.
11. Input the physician's street address, city, state, and zip code as required.
12. Ensure the physician signs the form, confirming completion and accuracy, and includes the date of signature.
13. Once all sections are complete, save the changes, download the form, print a copy, or share it as needed.

Complete the IL DPA 2390 online today to ensure timely processing of payment requests.