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FOR BHF USELL1 2016 STATE OF ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES FINANCIAL AND STATISTICAL REPORT (COST REPORT) FOR LONGER CARE FACILITIES (FISCAL YEAR 2016)I.DPH License ID Number: Facility

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Fill out each section of the form accurately and completely.

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Provide all required information such as name, date, and specific IV therapy being requested.

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Patients who require specific IV therapy treatments prescribed by their healthcare provider.

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Healthcare professionals who are prescribing or administering IV therapy treatments.

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