You must submit the following forms:

Note:  Payee Designation/Authorization Form (IL462-1180)

The Payee Designation/Authorization Form should be kept for your records for audit purposes.  The Department of Human Services does not require a copy of this document and does not retain this form for our records.

If not enrolled for DHS billing through the Reporting of Community Services (ROCS) system, the billing agent, group practice or limited liability corporation (LLC) completes the following forms:

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