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FOR BHF USELL1
2020STATE OF ILLINOIS
DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
FINANCIAL AND STATISTICAL REPORT (COST REPORT)
FOR LONGER CARE FACILITIES
(FISCAL YEAR 2020)
I.DPH License ID Number:
Facility
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Gather all necessary information such as personal details, dental insurance information, and reason for visit.
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Submit the completed form to the dental office either in person or through their preferred method of submission.
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What is oformr specify dental?
Oformr specify dental is a form used for specifying dental information.
Who is required to file oformr specify dental?
Dentists and dental clinics are required to file oformr specify dental.
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The purpose of oformr specify dental is to collect and report dental information for record-keeping purposes.
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Information such as patient demographics, treatment provided, and payment details must be reported on oformr specify dental.
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