Instructions for the Illinois Medical Assistance Program Provider Enrollment Application
Section A: Provider Information
- Check the appropriate box for type of enrollment (new, re-enrollment, name change, reinstatement).
- Provider Type: For Adult DD Waiver, enter Provider Type 91; for Children's Support Waiver, enter Provider Type 94; for Children's Residential Waiver, enter Provider Type 97.
It is important that you complete a separate HFS 2243 with the appropriate provider type for each waiver under which you will be providing services.
- Provider Name: Individual practitioners and individual personal support workers must last name first, then first name. The legal name must match the name on the provider agreement (HFS 1413A) and on the W9. Do not use middle initial or middle name unless that is the way the provider usually signs his/her name for checks.
- Numbers 4 - 7 are self-explanatory.
- Providers are required by the U.S. Postal Service to use a nine-digit zip code for all addresses. Mail without a nine-digit zip code may be returned by the U.S. Postal Service.
- Numbers 9 - 11 are self-explanatory.
- Enter National Provider Identification Number (NPI) if the provider is a health care provider, as defined in the Federal Health Insurance Portability and Accountability Act, which requires you to have an NPI.
- If enrolling as a business entity, enter your nine-digit Federal Employer Identification Number (FEIN) number of Federal Taxpayer Identification Number (FTIN). The FEIN or FTIN must match the FEIN or FTIN on the Provider Agreement (HFS 1413A) and on the W9. When completing this form, you must enter a SSN in box 12 or FEIN/FTIN in box 13. Do not enter a number in both boxes.
- If enrolling as an individual practitioner or personal support worker, enter your nine-digit Social Security number (SSN). The SSN must match the SSN on the Provider Agreement (HFS-1413A) and the W9.
- Individual practitioners licensed by the Illinois Department of Financial and Professional Regulation must enter their professional license number. Write in N/A for not applicable if you are not licensed by the Illinois Department of Financial and Professional regulation.
- Numbers 16 - 17 are not applicable.
- Enter the one-digit number to indicate the type of ownership:
- 1 = Sole Proprietary (for all individual providers)
- 2 = Partnership
- 3 = Corporation
- Enter the one-digit number to show the type of facility control:
- 1 = State, County or City
- 2 = Religious or charitable
- 3 = Proprietary (for all individual providers)
- 4 = Other
- Numbers 20 through 21 are not applicable.
SECTION B: Service/Specialty
- Enter the appropriate three-digit category of service code or codes from Attachment A.
- Numbers 23 through 38 are not applicable.
SECTION C: Former Participation
Complete this section only if there is a change of ownership, FEIN or name.
SECTION D: Additional NPI
SECTION E: Payee Information
Not Applicable at time of enrollment. Payee information will be accepted on each bill for service.
SECTION F: Certification/Signature
This section must be completed in its entirety. The Agreement must have an original signature of the individual, or if a business entity, an authorized person. You must also print the name of the signer legibly.
Provider handbook box is not applicable. Click on this link for the: Provider Waiver Manual