Enrollment in the Illinois Medical Assistance Program requires the complete of an application and determination of your eligibility prior to the assignment of a provider number. All providers are required to complete, sign, and date a Provider Agreement (HFS1413) and an Enrollment Disclosure Statement (HFS1513). It is the responsibility of the provider to ensure the accuracy of all information entered on this application.
All documents must be signed with original signature and date.
The completed Provider Enrollment Application (HFS2243), Medical Agreement (HFS1413), W-9, Disclosure Statement, and a copy of your Medicaid certificate should be mailed to:
- Jayne Antonacci
- 319 East Madison
- Suite 2D
- Springfield, IL 62701