Instructions for Agencies, Companies and Professionals - Developmental Disability Medicaid Waivers Only (Revised July, 2007)
Enrollment in the Illinois Medical Assistance Waiver Program requires the completion of this form, in addition to the Provider Enrollment Application form (HFS 2243) and the Request For Taxpayer Identification Number and Certification form (W-9). All information must be typed or printed and must be legible. To ensure prompt payment, this enrollment form, in addition to HFS 2243 and the W-9, must be completed and submitted before any services billed by the provider will be reimbursed by the Illinois State Comptroller.
A new HFS Form 1413A must be completed when a change of ownership, legal name, Federal Taxpayer/Employer Identification Number (FEIN), or Social Security Number (SSN) occurs.
Please mail or fax the completed and signed waiver agreement to:
Department of Human Services
Division of Developmental Disabilities
Medicaid Waiver Enrollment
319 E. Madison Street, Suite 3M
Fax: (217) 558-2799
Phone: (217) 782-3719
- First Blank Line: Enter the legal name of the agency, company or professional. The legal name must be the same as on the provider enrollment application and W-9.
- Second Blank Line: Enter the FEIN or SSN. The FEIN or SSN must be the same as on the provider enrollment application and W-9.
- Third Blank Line: Always enter "DHS Division of Developmental Disabilities."
- Fourth Blank Line: Always enter "DD Medicaid Waivers."
- Carefully read paragraphs one through 13 of the agreement .
- In paragraph 14, if applicable, print legibly or type in the name, SSN and percentage of ownership for the provider. This is not required if the provider is an individual.
- Go to paragraph 15 with blank line for agreement effective date. There must be a date entered here. The effective date must be the first day of the earliest month during which you have provided DD Medicaid Waiver services. The agreement effective date must have an original signature of the individual, or an authorized person of a business entity. On the blank line under the original signature, enter the applicable FEIN or SSN.
- Do not enter any information into the box entitled "FOR STATE AGENCY USE ONLY."
- DO NOT return these instructions.