This billing form may be used for Fee-for-Service Programs that are billed on a daily 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 an hourly 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.

Form Field Instructions
Provider Name Name of the agency providing the fee-for-service residential program to the individual.
Federal Taxpayer ID Number  (FTIN)  The number for reporting to the Internal Revenue System the taxable income paid to the agency. Also called the Federal Employer Identification Number (FEIN).
Program Code The Code for the fee-for-service program being billed. Billing for different programs must be entered on separate billing forms. Do not enter services for more than one program on the same bill.
Service Month 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.
Res.Loc. For 89D - Residential Respite DD. Enter the Residence Location Code where the individual is receiving services. The Code must match the information previously submitted on the paper provider information form (DD-1246).  Bill each residential location for a particular person/month on a separate form.
Individual SSN The Social Security Number for the individual receiving services.
Individual Name The legal name of the individual receiving services. For Medicaid waiver services, this must exactly match the name as it appears on the MediPlan card.
1-31 For each date of the service month (1-31) on which services were provided for this Program, please enter the appropriate code on each date.
  • P = Present
  • F = Bedhold - Family/Friends Visit
  • H = Bedhold - Hospitalization
  • C = Bedhold - Convalescent Care
  • S = Bedhold - Temporary Admission to a State-Operated Developmental Center
  • I = Bedhold - Incarceration
  • A = Non-Paid Date (or may be left blank)
Bedhold Codes Guidance For all bedhold codes (F, H,C, S, and I), a bedhold date is any date when the individual was absent for the entire date (from midnight to midnight).
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.
Telephone Number This is used to contact the provider in case of problems with the bill.

Submit completed billing forms to the address below. 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