You must submit the following forms:
- Payee Designation/Authorization Form (IL462-1180)
- The Payee Designation/Authorization Form should be kept by you and by the agency for which you work for audit purposes. The Department of Human Services does not retain a copy of this document.
- Copy of certification or licensure.
- If you are a Level 1 or Level 2 Behavior Intervention Services provider, you must submit your approval letter
- Send the completed documents to the address below:
Illinois Department of Human Services
Division of Developmental Disabilities
319 E. Madison Street, Suite 3M
Springfield, IL 62701
Fax: (217) 558-2799
Attention: Provider Enrollment
If the agency for which you are working is not enrolled for DHS billing through the Reporting of Community Services (ROCS) system, the agency must complete the following forms and submit them to Janene.VanBebber@illinois.gov:
to any DHS program will be denied if the provider of health care services does not have an NPI number registered with HFS. Your NPI number is registered by HFS at the time of enrollment. The NPI number is entered on your form HFS 2243.