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.
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
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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