How Do I Become A Provider?

  1. You must obtain your National Provider Identification Number.
  2. You must complete an online application to enroll in the IMPACT provider enrollment system. Please visit the DHS/DDD IMPACT page for additional information specific to the DD Medicaid Waiver Program(s).  Please complete the enrollment application as a Rendering/Servicing Only provider.  You must disclose who on your IMPACT application who is your billing provider.After submitting an IMPACT application, please email Provider Enrollment the IMPACT application ID to ensure that the application is reviewed by a DDD Provider Enrollment specialists.
  3. Complete a Payee Designation/Authorization Form (IL462-1180).  This document should be maintained on record by the billing provider. 

Important Resources for Requirements