This billing form may be used for Fee-for-Service Programs that are billed on an hourly basis. Agencies that have access to the Reporting of Community Services (ROCS) software must bill via File Transfer Protocol (FTP).Different billing forms are used for fee-for-service programs that are billed on an event basis or on a daily basis.
The following instructions will assist in completing the form. If there are questions, please contact the case manager for the individual for additional information.
||Name of the company, agency, independent contractor or individual therapist providing the fee-for-service program to the individual.
|Federal Taxpayer ID No. (FTIN)
||The number for reporting to the Internal Revenue System the taxable income paid to the agency or company, independent contractor or therapist. Also called the Federal Employer Identification Number (FEIN). May be the independent contractor or therapist's Social Security Number (SSN).
||Name of the company, agency or individual therapist that should be paid for the fee-for-service program. If same as provider, write in SAME.
||The Code for the fee-for-service program being billed. Billing for different programs or at different rates (Respite - 87D, Behavior Intervention - 56U, or Emergency Home Response - 55W) must be entered on separate billing forms. Do not enter services for more than one program/rate on the same bill.
||The Service Month for which the billing information is being provided. This is the month and the year of service, listed as six digits. Examples: 012007=January 2007; 102007=October 2007. Enter only one month on each bill. Do not overlap months on the same bill.
||For applicable programs (87D, 56U, 55W), enter the Rate Level Code (1, 2, or 3) that corresponds to the appropriate rate for the hours being billed. Bill each rate level for a particular person/month on a separate billing form.
||The Social Security number for the individual receiving services.
||The legal name of the individual receiving services.
||For each date of the service month (1-31) on which services were provided for this Program, please enter the amount of time in hours and minutes. Time may be rounded to the nearest 30 minutes - 1/2 hour or 15 minutes -1/4 hour. For nursing, and professional therapy (OT,PT, speech, behavioral) services, time may be in minutes or may be rounded to the nearest 1/4 hour.
|Mileage / Overnights
||Mileage: For in-home respite (87D) only, enter the monthly total dollar amount being billed for mileage in the Mileage field. Overnights: Enter the monthly total dollar amount being billed for overnight stays in the home (@ $10 per date) in the Overnights field. This field may be used only if the daily maximum number of hours has been billed.
|Certification and Approval
||Signatures affixed below this section attest that the provider has met the conditions stipulated herein.
|Service Provider Certification
||Service provider must sign and date the form here to certify that the services were delivered in accordance with requirements. Unsigned bills will not be processed for payment.
||This is used to contact the provider in case of problems with the bill.
Submit completed billing forms to the address below. The first billing form submitted must include a copy of the Internal Revenue Service form W-9, and information on the County and Township in which the provider is located. If your agency has ROCS, do not submit paper bills.
Programmatic Vouchering Unit
DHS Office of Clinical, Administrative, and Program Support
401 North 4th Street 2nd floor
Springfield, Illinois 62765