This billing form may be used for fee-for-service programs that are billed on an event basis. Agencies that have access to the Reporting of Community Services (ROCS) software must bill via File Transfer Protocol (FTP). A different form is used to bill for fee-for-service programs which are billed on an hourly 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 or independent contractor providing the fee-for-services 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, company or individual contractor. Also called the Federal Employer Identification Number (FEIN). Independent contractors may use the Social Security Number (SSN).
||Name of the company, agency or independent contractor 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 must be entered on separate billing forms. Do not enter services for more than one program 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 Emergency Home Response (55W) only, specify Rate Level 1 for installation only. Specify Rate Level 2 for monthly fees.
||The Social Security number for the individual receiving services.
||The name of the individual receiving services.
||For each date of the month service month (1 through 31) on which services were provided for this Program, please enter on the longer line, in dollars and cents, the TOTAL AMOUNT expended on that date (e.g., "$15.65"); and enter on the shorter line following it, the TOTAL NUMBER OF EVENTS for that day (e.g, 1, 3, etc.). For example, if an individual on the 12th day of the month went to the county fair for $7.75 in taxi fare and took the bus to the grocery store for $2.00, the entry would look like this: "12 $9.75 2 " : on the 12th day, a total of $9.75 was spent and 2 events occurred.
|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