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Health Financial Systems MIDWESTERN REGIONAL MEDICAL CENTER In Lieu of Form CMS255210 This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM
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Obtain the required application form from the State of Illinois website or request a physical copy by contacting the appropriate department.
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Healthcare providers, including doctors, nurses, therapists, and other medical professionals, who wish to practice in the state of Illinois.
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State of Illinois provider refers to a healthcare provider who offers services within the state of Illinois.
Healthcare providers who operate within the state of Illinois are required to file as state of Illinois providers.
Providers can fill out the state of Illinois provider form online or through the appropriate state agency.
The purpose of the state of Illinois provider filing is to ensure that healthcare providers are properly registered and recognized by the state.
Information such as provider name, contact information, services provided, and any relevant certifications or licenses must be reported on the state of Illinois provider form.
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