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:

You must obtain your National Provider Identification Number

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.

Important Resources for Requirements