PM 21-05-08.

  1. (Worker) Complete 3 copies of Referral for Medical Examination (Form 1864) for required physical examinations. Use the instructions on the form.
    1. Indicate the reason for the physical.
    2. Tell the client to give both the original and first copy to the medical provider. File the 2nd copy in the case record.
  2. (Medical Provider) Submits the original Form 1864 with Health Insurance Claim Form (Form 2360) to the worker who made the referral. The provider keeps the copy for their own records.
  3. (Worker) Prepare an Invoice-Voucher (Form C-13), leaving the payment amount and the signature areas blank. Batch Form 1864, Form 2360, and Form C-13 and send them for processing to:

    Bureau of Claims Processing
    PO Box 19105
    Springfield, IL 62794-9151