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FOR BHF USELL1 2010 STATE OF ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES FINANCIAL AND STATISTICAL REPORT (COST REPORT) FOR LONGER CARE FACILITIES (FISCAL YEAR 2010)I.DPH License ID Number:
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Step 1: Begin by providing your full name and address in the designated spaces on the form.
02
Step 2: Enter your Social Security Number in the appropriate field.
03
Step 3: Indicate the coverage months for which you are reporting on the form.
04
Step 4: If you had any dependents covered by the same health insurance plan, include their information as well.
05
Step 5: Sign and date the form to certify that the information you provided is accurate.
06
Step 6: Keep a copy of the completed form for your records and submit the original to the appropriate entity as instructed.
07
Step 7: If you have any questions or need assistance, refer to the instructions provided by the entity requesting the form or consult a tax professional.

Who needs 1095 university drive?

01
Individuals who have health insurance coverage through the University at the address mentioned, 1095 University Drive, need to fill out the form 1095 with their coverage information.
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