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

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

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

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

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Enter a free-form illness or injury description that includes the major body part allegedly injured and the cause.

57 | DESCRIPTION OF ALLEGED ILLNESS OR INJURY | Enter a free-form text description of alleged illness or injury. Include description of major body part allegedly injured (e.g. head, arm, leg, etc.) and cause of alleged illness/injury.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Indicate the representative type using the listed options; if there is more than one representative, provide attorney information if available.

84 | REPRESENTATIVE TYPE | Indicate the type of representative that the Alleged Injured Party has. Select from the options provided: A = Attorney G = Guardian/Conservator P = Power of Attorney O = Other Blank = None If Alleged Injured Party has more than one representative, provide attorney information if available.

WARNINGCivil cases

Applies to

Evidence of continuing education

Approved parenting coordinators must provide evidence of completed continuing education to the Chief Judge or designee every two years.

The approved parenting coordinator must provide evidence of completion of this continuing education to the Chief Judge or his/her designee every two (2) years.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

If TPOC funding is delayed, provide the actual or estimated funding date.

102 | FUNDING DELAYED BEYOND TPOC (ACUTAL OR ESTIMATED DATE OF FUNDING) | If funding for the TPOC is delayed, provide actual or estimated date of funding.

WARNINGCivil cases

Applies to

Form

If the injured party is not deceased and the spouse-related exception does not apply, stop completing the form and sign on Page 10.

If you have completed this page in its entirety and Alleged Injured Party in Section A is not deceased, stop here and sign on Page 10 UNLESSthe Injured Party's Spouse is or was a Medicare benefidary and claimed or is releasing personal injuries.

WARNINGCivil cases

Applies to

Fact witness list

The fact witness lists should set forth possible fact witnesses known to that party by name.

The fact witness lists should set forth possible fact witnesses known to that party by name.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 43 ICD-9 diagnosis code follows the explanation for Field 19.

43 | ICD-9 DIAGNOSIS CODE 13 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The form requires the industry date of incident, using the specified accident or last-exposure, ingestion, or implantation date.

Provide Industry Date of Incident (DOl) routinely used by the insurance/workers' compensation industry: For an automobile wreck or other accident, the date of incident is the date of the accident. For ciaims involving exposure, or implantation, the date of incident is the date of LAST exposure, ingestion, or implantation.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 53 ICD-9 diagnosis code follows the explanation for Field 19.

53 | ICD-9 DIAGNOSIS CODE 18 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the mailing-address city for the representative named above.

91 | CITY | Provide mailing address city for the alleged injured party's representative named above.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the representative’s mailing ZIP code with ZIP+4 if known; otherwise enter 0000.

93 | ZIP CODE +4 | Provide mailing address zip code for the alleged injured party's representative named above. Include Zip+4 code if known; if not known enter 0000.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The form requires the CMS date of incident, determined by the specified accident, exposure, ingestion, or implant rules.

Provide Date of Incident (DOt). DOl as defined by CMS: For an automobile wreck or other accident, the date of incident is the date of the accident. For ciaims involving exposure (including, for example, occupational disease and any associated cumulative injury) the DOl is the date of FIRST exposure. For claims involving ingestion (for example, a recalled drug), it is the date of FIRST ingestion. For claims involving implants it is the date of the implant (or date of the first implant if there are multiple implants).

WARNING

Applies to

Document containing third party signatures

Documents with third-party signatures may be filed electronically and must bear a facsimile or typographical signature.

Documents containing signatures of third parties may be filed electronically and shall bear a facsimile or typographical signature.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

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

6 | LAST NAME | Provide last name of Alleged Injured Party EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or Medicare Card if available.

WARNINGCivil cases

Applies to

Medicare reporting form

State the alleged cause of the injury, incident, or illness and provide the corresponding ICD-9-CM code or codes.

15. Alleged Cause of Injury, Illness or incident: Please state the alleged cause of injury, incident or illness and the ICD·9-CM (lnternationill Classification of Diseases, Ninth Revision, Clinical Modification code(s)) with respect to the same. **

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 33 ICD-9 diagnosis code follows the explanation for Field 19.

33 | ICD-9 DIAGNOSIS CODE 8 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Final mediator report

When mediation ends without agreement, the mediator must file a final report stating that mediation concluded without disclosing why the parties did not agree.

Upon termination without agreement, the mediator shall file with the court a final mediator report stating that the mediation has concluded without disclosing any reasons for the parties' failure to reach an agreement.

WARNINGCivil cases

Applies to

Form b

The form directs the filer to continue to Section E only if the injured party is deceased.

Please continue to Section E (Contain information) only If Alleged Injured Party is Section A is deceased.

WARNING

Applies to

Approved attorney list submission

Attorneys must complete and return the circuit’s Child Representative Information Sheet with a statement or other verification of continuing-education attendance.

Each attorney must complete the Child Representative Information Sheet provided by this circuit and return it with a statement or other verification of attendance at continuing education.

WARNINGCivil cases

Applies to

Deposition tender

A deposition tender is a written indication of when and where a witness will be produced without a subpoena.

A tender is a written indication of when and where a witness will be produced for deposition without subpoena.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the representative’s TIN, using the firm’s EIN for a firm representative or the representative’s SSN otherwise.

88 | TIN/EIN, IF FIRM/ENTITY; SOCIAL SECURITY NUMBER IF INDIVIDUAL | Provide Alleged Injury Party's Representative's Federal Tax Identification Number (TIN). If representative is part of a firm, supply the firm's Employer Identification Number (EIN), otherwise supply the representative's Social Security Number (SSN).

WARNINGCivil cases

Applies to

Medicare reporting form

Provide valid ICD-9 codes for each alleged injury or illness arising from the allegations against the settling defendant.

19. ICD-9 Diagnosis Code 1: Please provide valid ICD-9 Codes for any injury or illness you allege arose from the allegations made agilinst settling defendilnt.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the injured party’s date of birth.

10 | DATE OF BIRTH | Provide Alleged Injured Party's Date of Birth.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

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

Provide last name of Alleged Injured Party EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or Medicare Card if available.

WARNINGCivil cases

Applies to

Settlement agreement

As a best practice, the release or settlement agreement should state that settlement funds may need to be held by plaintiff's counsel.

This Court also regards it as best practice that the release or settlement agreement should state in some manner that settlement funds may need to be held by plaintiff's counsel.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the incident date using the specified CMS date for accidents, exposure, ingestion, or implants.

12 | CMS DATE OF INCIDENT | Provide Date of Incident (DOI). DOI as defined by CMS: For an automobile wreck or other accident, the date of incident is the date of the accident. For claims involving exposure (including, for example, occupational disease and any associated cumulative injury) the DOI is the date of FIRST exposure. For claims involving ingestion (for example, a recalled drug), it is the date of FIRST ingestion. For claims involving implants it is the date of the implant (or date of the first implant if there are multiple implants).

WARNINGCivil cases

Applies to

Form

SIGNATURE/A TTESTATION PLEASE SIGN ON PAGE 10

SIGNATURE/A TTESTATION PLEASE SIGN ON PAGE 10

WARNING

Applies to

Continuing education verification

Attorneys remaining on the approved list must submit verification of continuing-education attendance every two years, upon request, or as otherwise directed.

To remain on the approved list, each attorney shall attend continuing legal education courses consisting of at least ten hours every two-year period and submit verification of attendance every two years or upon request to the Office of the Chief Judge or as otherwise directed.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 29 ICD-9 diagnosis code follows the explanation for Field 19.

29 | ICD-9 DIAGNOSIS CODE 6 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Confidentiality agreement

All mediation participants must sign the prescribed confidentiality agreement before mediation begins.

Prior to the commencement of mediation, all participants in the mediation shall sign the confidentiality agreement prescribed by these rules.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The form requires the alleged injured party’s gender to be indicated by selecting MALE or FEMALE.

Indicate Alleged Injured Party's gender by selecting MALE or FEMALE.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Indicate the injured party’s gender by selecting MALE or FEMALE.

9 | GENDER | Indicate Alleged Injured Party's gender by selecting MALE or FEMALE.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Use a Field 19 ICD-9 diagnosis code on CMS’s current list of valid codes; at least one valid diagnostic code must not be an insufficient code, an E code, or a V code.

19 | ICD-9 DIAGNOSIS CODE 1 | (International Classification of Diseases, Ninth Revision, Clinical Modification) - Must be on the current list of valid codes accepted by CMS found at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/06_codes.asp. At least one valid diagnostic code must NOT be on the list of insufficient codes (found in Appendix H to the NGHP User Guide, V. 2.0, and NOT and E or a V Code).

WARNINGCivil cases

Applies to

Authorization to release information form

If applicable, the Medicare number on the authorization form must be the number shown on the Medicare card.

MEDICARE NUMBER (HICN): _____ (if applicable, the number on your Medicare card)

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 23 ICD-9 diagnosis code follows the explanation for Field 19.

23 | ICD-9 DIAGNOSIS CODE 3 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Authorization to release information form

If applicable, the name on the authorization form must match the name shown on the Medicare card.

NAME: _____ (if applicable, exactly as shown on your Medicare card)

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 51 ICD-9 diagnosis code follows the explanation for Field 19.

51 | ICD-9 DIAGNOSIS CODE 17 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Medicare reporting form

Print the injured party’s last name exactly as it appears on the Social Security card.

6. Injured Party Last Name: (Please print name exactly as it appears on Social Security card.)

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the industry date of incident, using the accident date for accidents and the last exposure, ingestion, or implantation date for the specified claims.

13 | INDUSTRY DATE OF INCIDENT | Provide Industry Date of Incident (DOI) routinely used by the insurance/workers' compensation industry: For an automobile wreck or other accident, the date of incident is the date of the accident. For claims involving exposure, or implantation, the date of incident is the date of LAST exposure, ingestion, or implantation.

WARNINGCivil cases

Applies to

Medicare reporting form

If the injured party is deceased, complete Sections F and G.

(if party is DECEASED,also complete Section F and Section G)

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 21 ICD-9 diagnosis code follows the explanation for Field 19.

21 | ICD-9 DIAGNOSIS CODE 2 | See explanation for Field 19.

WARNINGCivil cases

Applies to

Form b

Use the continued Section F claimant information only if the alleged injured party is deceased.

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

WARNINGCivil cases

Applies to

Mediator notice

The mediator must immediately notify the court in writing of a suspension, termination, or party noncompliance, identifying any party who failed to appear.

The mediator shall immediately advise the court in writing if he or she suspends or terminates mediation or in the event that either or both parties fail to comply with the terms of this Rule, including whether one or both of the parties failed to appear and the identity of the party who did not appear.

WARNINGCivil cases

Applies to

Form b

Please continue to Section E (Claimant Information) only if Alleged Injured Party in Section A is deceased.

Please continue to Section E (Claimant Information) only if Alleged Injured Party in Section A is deceased.

WARNINGCivil cases

Applies to

Confidential juror questionnaire

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

## CONFIDENTIAL JUROR QUESTIONNAIRE ANSWERED UNDER OATH Juror Name: _____ Place of birth (City/State). _____ Age ____ Gender: ____ City or Village where you live now: _____ How long? ____ yrs Zip code: _____ How long you have lived in Madison County? ____ yrs Do you have a court case pending in Madison County? ( ) Yes ( ) No I swear the above answers are true to the best of my knowledge. _____ (Sign)

WARNINGCivil cases

Applies to

Fact witness list

A party may describe witness categories when names are unknown, but must supplement the list if the names become known.

Any party may list categories of witnesses by description to the extent that the names of those witnesses are unknown, but must supplement its list if-names become known.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Provide the name of the representative’s firm.

87 | REPRESENTATIVE FIRM NAME | Provide the Name of the Representative's Firm.

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

Indicate whether the injured party is deceased by selecting YES or NO.

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

WARNINGCivil cases

Applies to

Medicare mandatory reporting information form

The Field 39 ICD-9 diagnosis code follows the explanation for Field 19.

39 | ICD-9 DIAGNOSIS CODE 11 | See explanation for Field 19.