You must submit the following forms, Encrypted, to Janene.VanBebber@illinois.gov or the address provided below:
Illinois Department of Human Services
Division of Developmental Disabilities
600 East Ash, Building 400, Mail Stop 3
Springfield, IL 62703
Attention: Provider Enrollment
Note: 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.