Illinois State Student Health Insurance Form For Providers

Please contact student health insurance at 309 438 2515 for terms and conditions.

Illinois state student health insurance form for providers. Room 303 student services building illinois state university normal il 61790 2541 phone. Ub92 or ub04 billing from a hospital. The online form requires adobe acrobat reader or you may pick up a form at the student health insurance office. Numerous dentists participate in the vicinity of illinois state and are also available all over the country.

A completed aetna claim form. Accepted forms are hcfa 1500 billing from a physician. The student health insurance plan does not cover dental services with the exception of some limited benefits mandated by the affordable care act for insureds 18 years of age and younger see brochure for details. Provider forms request springfield hfs 1517 pdf.

Health insurance claim form example only hfs 2360 ocr pdf. Urbana il 61801 insure illinois edu 217 333 0165. For the health and safety of students and staff student health insurance requests customers to please call 309 438 2515 and to mail student insurance campus box 2541 normal il 61790 or fax medical claims if possible. Student health insurance the student health insurance office has reopened.

Students whose withdrawal dates are after the 15th calendar day of the term 8th day for the summer session will retain student health insurance for the remainder of the term. Forms illinois national health service corps state loan repayment program. These forms are downloadable and available in adobe portable document format pdf. 2020 professional practice student health insurance certification form use for fall 19 spring 20 and summer 20.

An itemized bill from the provider of the service. Office of student health insurance 1109 s. Long term care provider agreement state operated facility provider type 34 hfs 1433 pdf mch primary care provider agreement hfs 3411a pdf. Student health insurance certification forms.

Certificate of religious exemption form.