3rd Judicial Circuit Court, Madison County, Illinois Document Filing Requirements

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The form requires the deceased status of the alleged injured party to be indicated by selecting YES or NO.

Indicate if the Alleged Injured Party is deceased by selecting YES or NO.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

For claims submitted before January 1, 2011, provide either the cause code and a valid ICD-9 diagnosis code or the illness/injury description; for claims submitted on or after that date, provide the cause code and a valid ICD-9 diagnosis code, and do not submit the description.

15 | ALLEGED CAUSE OF INJURY, ILLNESS OR INCIDENT | Claims submitted prior to 1/1/11, Claimant must provide either: 1) both a valid Alleged Cause of Injury, Incident or Illness Code (Field 15) and at least one valid ICD-9 Diagnosis Code (Field 19) OR 2) the Description of Illness/Injury (Field 57). Claims submitted on or after 1/1/11, Claimant must provide both a valid Alleged Cause of Injury, Incident, or Illness Code (Field 15) and at least one valid ICD-9 Diagnosis Code. A description of Illness/Injury (Field 57) will not be accepted on or after 1/1/11.

WARNINGCivil cases

Applies to

Juror questionnaire

The juror questionnaire includes an oath that the answers are true to the juror’s knowledge, followed by a signature line.

I swear the above answers are true to the best of my knowledge. _____ (Sign)

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The form requires the alleged injured party’s date of birth.

Provide Alleged Injured Party's Date of Birth.

WARNINGCivil cases

Applies to

Foreclosure mediation forms

Attorneys may generate forms for foreclosure mediation cases if the forms are substantially similar to court-approved forms.

Attorneys may generate forms for use in foreclosure mediation cases as long as they are substantially similar to the forms approved by the court.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The form requires the postal abbreviation for the state whose law controls the claim, or “US” for the specified federal claims.

Provide the US postal abbreviation corresponding to the US State whose state law controls resolution of the claim. Use ·US· where the claim is a Federal Tor Claims Act liability insurance matter or a Federal workers' compensation claim.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the injured party’s middle initial exactly as it appears on an available Social Security or Medicare card.

8 | MIDDLE INITIAL | Provide middle initial of Alleged Injured Party EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or Medicare Card if available.

WARNINGCivil cases

Applies to

Medicare reporting form

Print the injured party’s first and middle names exactly as they appear on the Social Security card.

7 • Injured Pilrty First Name: 8. Injured Pilrty Middle Name: (Please print name exactly as it appears on Social Security card.) (Please print name exactly as it appears on Social Security card.)

WARNINGCivil cases

Applies to

Contribution counterclaim

A defendant may instead file a separate contribution counterclaim with the Circuit Clerk identifying the defendants sued; doing so abandons the counterclaims, responsive pleadings, and affirmative defenses deemed filed under Section B.2(a).

(b) A defendant may elect to forego the provisions of Section B.2(a) and proceed to file a counterclaim for contribution with the Circuit Clerk separately identifying the various defendants against whom the contribution action is brought. Any counter-claimant who files a Contribution action with the Circuit Clerk shall be deemed to have abandoned any counterclaims, responsive pleadings and affirmative defenses deemed filed as provided in Section B.2(a).

WARNINGCivil cases

Applies to

Fact witness list

Failure to properly list a witness may lead to exclusion of that witness’s trial testimony unless the witness was otherwise fairly disclosed.

The failure to properly list a witness on a party’s fact witness list may be grounds for excluding the witness’ testimony at trial, unless the witness is otherwise fairly disclosed.

WARNINGCivil cases

Applies to

Deposition upon written questions

The Court-approved “Deposition Upon Written Questions” set must continue to be used as the standard set for future respondents in discovery.

The standard set of questions entitled: "Deposition Upon Written Questions," which was previously approved by the Court for deposing respondents in discovery shall continue to be the standard set used for future respondents in discovery.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the representative’s telephone number.

95 | PHONE | Provide telephone number of alleged injured party's representative.

WARNINGCivil cases

Applies to

Form section

Complete Section F only if the injured party's spouse was or is a Medicare beneficiary.

Please continue to Section F (Spouse Information) only if the Injured Party's spouse is or was a Medicare beneficiary.

WARNING

Applies to

Electronically filed document

Signatures under Rule 9 satisfy applicable signature rules and statutes and may be subject to available sanctions when appropriate.

Signatures as defined in this Rule 9, satisfy Supreme Court Rules and statutes regarding signatures, and give rise to the application of available sanctions when appropriate.

WARNING

Applies to

Report

Sitting judges must also report cases and the reasons for delay to the Chief Judge’s Office.

Rule 3. In addition to the notation requirement aforementioned, the sitting judges shall also report said case(s) with the reason for the delay to the Chief Judge’s Office. (See attached form for reporting).

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 25 ICD-9 diagnosis code follows the explanation for Field 19.

25 | ICD-9 DIAGNOSIS CODE 4 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the injured party’s Medicare claim number if one has been issued and is available.

4 | MEDICARE CLAIM NUMBER (HICN) | Provide Alleged Injured Party's Medicare Health Insurance Claim Number (if one has been issued). This number can be found on Medicare Card if available.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 55 ICD-9 diagnosis code follows the explanation for Field 19.

55 | ICD-9 DIAGNOSIS CODE 19 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Award

If the arbitrators unanimously find a violation of Rule 91(b)'s good-faith provision, the finding and its factual basis must be recorded on a findings sheet that becomes part of the award.

(b) In the event the panel of arbitrators unanimously finds that a party has violated the good-faith provision of Supreme Court Rule 91(b), such finding accompanied by a factual basis shall be noted on a findings sheet. Such finding sheet shall become part of the award.

WARNINGCivil cases

Applies to

Mediator designation stipulation

Within 14 days after the referral order, the parties may submit a stipulation designating a certified mediator or, subject to the stated qualifications and approval, a non-certified mediator.

Within 14 days of the Order of Referral, the parties may agree upon a stipulation with the court designating: a. A certified mediator; or b. A mediator who does not meet the certification requirements of these rules but who, in the opinion of the parties and upon review by and approval of the presiding judge, is otherwise qualified by training or experience to mediate all or some of the issues in the particular case.

WARNINGCivil cases

Applies to

Mediator agreement account

The mediator must provide the parties and their attorneys a written account of any agreements or partial agreements, but may provide it to the court only with the parties’ written consent.

When agreements or partial agreements are reached by the parties during mediation, the mediator shall provide a written account of the agreements to the parties and their attorneys (if any), but the mediator shall not provide this written account to the court unless the parties consent in writing that the mediator may do so.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 31 ICD-9 diagnosis code follows the explanation for Field 19.

31 | ICD-9 DIAGNOSIS CODE 7 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Response pleading

Filing a response to a deemed-filed counterclaim is deemed to abandon the counterclaims, responsive pleadings, and affirmative defenses under Section B.2.a., unless the Court orders the pleading.

A defendant which files a pleading with the Circuit Clerk in response to a deemed filed counterclaim abandons any counterclaims, responsive pleadings and affirmative defenses deemed filed as provided in Section B.2.a., except when ordered by the Court to file such a pleading.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the injured party’s first name exactly as it appears on an available Social Security or Medicare card.

7 | FIRST NAME | Provide first name of Alleged Injured Party EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or Medicare Card if available.

WARNINGCivil cases

Applies to

Form b

If you have completed this page in its entirety and Alleged Injured Party in Section A is not decreased, stop here.

If you have completed this page in its entirety and Alleged Injured Party in Section A is not decreased, stop here.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 41 ICD-9 diagnosis code follows the explanation for Field 19.

41 | ICD-9 DIAGNOSIS CODE 12 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the representative’s first name.

86 | REPRESENTATIVE FIRST NAME | Provide First Name of Representative.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the mailing address of the representative named above.

89 | MAILING ADDRESS | Provide mailing address for the alleged injured party's representative named above.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Enter the release-signing date as the settlement date unless court approval is required, in which case use the later date; if there is no written agreement, use the payment date.

100 | DATE OF SETTLEMENT | Date the Release is signed unless court approval is required - then it is the later of the date the Release is signed or the date of court approval. If there is no written agreement, then it is the date of payment.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The alleged injured party’s middle initial must be entered exactly as it appears on a Social Security or available Medicare card.

Provide middle initial of Alleged Injured Party EXACTlY AS IT APPEARS ON SOCIAL SECURITY CARD or Medicare Card if available.

WARNINGCivil cases

Applies to

Form

If the injured party is not deceased and the spouse-related exception does not apply, the filer may stop and sign on Page 10 after completing Pages 1 and 2.

If Alleged Injured Party is NOT DECEASED and you have completed Page 1 & 2, you may stop here and sign on Page 10, UNLESS the Injured Party's spouse is or was a Medicare beneficiary and claimed and/or is releasing personal injuries.

WARNINGCivil cases

Applies to

Proposed docket

Cases will be grouped for trial according to a proposed docket submitted by the lawyer or law firm representing the plaintiffs.

Cases will be grouped for trial according to a proposed docket submitted by the lawyer or law firm representing the plaintiffs.

WARNINGCivil cases

Applies to

Homeowner financial questionnaire

The homeowner financial questionnaire must be completed and brought to the Initial Intake Conference.

Please complete this form and bring it with you to the Initial Intake Conference.

WARNING

Applies to

Electronic document requiring clerk endorsement

When a Clerk must endorse an electronic document, the Clerk’s typed name is deemed the Clerk’s signature.

Where a Clerk is required to endorse a document, the typed name of the clerk shall be deemed to be the clerk’s signature on an electronic document.

WARNINGCivil cases

Applies to

Written stipulation to mediate

The parties may file a written stipulation to mediate an issue at any time, and the stipulation must be incorporated into an order of referral.

In addition, the parties to any such matter may file a written stipulation to mediate any issue between them at any time. Such stipulation shall be incorporated into an order of referral.

WARNING

Applies to

Electronically filed document

Without a facsimile or typographical signature, an e-filed document submitted using a user ID and password is deemed personally signed by the credential holder.

In the absence of a facsimile or typographical signature, any document electronically filed with user identification and password is deemed to have been personally signed by the holder of the user identification and password.

WARNINGCivil cases

Applies to

Form b section a claimant information

Use the continued claimant-information section only if the alleged injured party is deceased.

Section A continued CLAIMANT INFORMATION (Use only if Alleged Injured Party in Section A is deceased)

WARNING

Applies to

Electronically filed document

An electronically filed document using verified court-issued or authorized-provider authentication is deemed signed by the authentication holder.

Any document filed electronically using a verified user authentication issued by the court or its authorized provider shall be deemed to have been signed by the holder of the user authentication.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 49 ICD-9 diagnosis code follows the explanation for Field 19.

49 | ICD-9 DIAGNOSIS CODE 16 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the postal abbreviation for the state whose law controls the claim, or enter “US” for the specified federal claims.

17 | STATE OF VENUE | Provide the US postal abbreviation corresponding to the US State whose state law controls resolution of the claim. Use "US" where the claim is a Federal Tor Claims Act liability insurance matter or a Federal workers' compensation claim.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 35 ICD-9 diagnosis code follows the explanation for Field 19.

35 | ICD-9 DIAGNOSIS CODE 9 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the representative’s last name.

85 | REPRESENTATIVE LAST NAME | Provide Last Name of Representative.

WARNINGCivil cases

Applies to

Contribution action

Filing a separate contribution action with the Circuit Clerk is deemed to abandon the counterclaims, responsive pleadings, and affirmative defenses deemed filed under Section B.2.a.

Any counterclaimant which files a Contribution action with the Circuit Clerk shall be deemed to have abandoned any counterclaims, responsive pleadings and affirmative defenses deemed filed as provided in Section B.2.a.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the injured party’s Social Security number if the Medicare claim number is unavailable.

5 | SOCIAL SECURITY NUMBER | Provide Alleged Injured Party's Social Security Number if Medicare Claim Number (HICN) is not available.

WARNINGCivil cases

Applies to

Medicare reporting form

State the accident date or the date of last exposure, ingestion, or implantation for the settling defendant’s product or premises.

13. Industry Date of Incident: Pleilse state the dilte of accident or date of last exposure, ingestion, or lmplantatlon with respect to settling defendant's product and/or premises.

WARNINGCivil cases

Applies to

Supplemental expert report

A case-specific expert who reviews additional materials need not provide a supplemental report unless the review changes or alters the expert’s opinion.

Any case-specific expert that reviews additional materials does not have to provide a supplemental report unless it changes or alters their opinion.

WARNINGCivil cases

Applies to

Medicare reporting form

State the accident date or the date of first exposure, ingestion, or implantation for the settling defendant’s product or premises.

12. CMS Date of Inddent: Pleilse state the date of accident or date of first exposure, ingestion, implantatlon with respect to settling defendant's product and/or premises.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 27 ICD-9 diagnosis code follows the explanation for Field 19.

27 | ICD-9 DIAGNOSIS CODE 5 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare reporting form

Provide a separate ICD-9 code for each body part alleged to have been affected.

NOTE: sepilrilte IC0-9 codes are required for each body part you assert waslis affected.

WARNINGCivil cases

Applies to

Form section

Complete Section G only if the alleged injured party is deceased.

Please continue to Section G (Claimant Information) only if Alleged Injured Party in Section A ;s deceased.