You must submit the following documents:

  1. Letter of Interest 
  2. Waiver Program Provider Agreement (HFS 1413A) 
  3. Provider Enrollment Application (HFS 2243)
  4. IRS W-9 form and Guidelines
  5. Provider Information Form (IL462-1246) 
  6. FTP Registration Request Form 
  7. Community Provider User ID and System Access Request  (IL444-2022)

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