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 Medical Vendors Form 2016-2023

Medical Vendors Form 2016-2023

Use a 2016 il cc 93 1 vendors fillable template to make your document workflow more streamlined.

Credits. Exhibits A B and C are made a part of this Complaint. Claimant is enrolled as a participant in the Department s Medical Assistance Program and has complied with the Department s requirements and regulations as applicable to the subject medical services. Claimant s Signature Ref Section 11-13 Chpt. 23 Ill. Revised Statutes as amended. IDPA Medical-Service provider Vendor Printed by authority of the State of Illinois - December 2016 - 1 - CC 93. 2 Claimant s Attorney Street Address City...
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