A Professional who is Reimbursed Via Other Means

You must submit the following forms:

• Letter of Interest
• Waiver Program Provider Agreement (HFS 1413A)
  • Instructions for HFS 1413A
• Provider Enrollment Application (HFS 2243)
  • Instructions for HFS 2243 

  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 agency, group practice or limited liability corporation (LLC) completes the following Medicaid Waiver enrollment forms:

• IRS W-9 form and Guidelines
• Provider Information Form (IL462-1246)
• Community Provider User ID and System Access Request  (IL444-2022)
• FTP Registration Request Form 

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