Independent Provider - Directly Reimbursed

You must submit the following documents:

• Letter of Interest 
• Waiver Program Provider Agreement (HFS 1413A) 
  • Instructions for HFS 1413A
• Provider Enrollment Application (HFS 2243)
  • Instructions for HFS 2243 
• IRS W-9 form and Guidelines
• Provider Information Form (IL462-1246)
• FTP Registration Request Form 
• Community Provider User ID and System Access Request  (IL444-2022)

You must obtain your National Provider Identification Number 

Send the completed documents to the address below:

Department of Human Services
Division of Developmental Disabilities
319 E. Madison Street, Suite 3M
Springfield, IL 62701
Fax:  (217) 558-2799

Attention:  Provider Enrollment

Important Resources for Requirements