Printable Time Sheets and Provider Employment Packet

Time Sheets

Payroll Schedules

HSP Overtime

Program Compliance

Submitting Timesheets

The forms within this page are necessary to begin working as an individual provider for a customer under the Division of Rehabilitation Services (DRS) Home Services Program (HSP). These forms are an employment application to work for an HSP Customer and must be completed in their entirety and returned to the customer's local DRS office. If the customer is also enrolled in a Managed Care Organization (MCO), these documents will still be turned into the customer's local DRS office.

Before an Individual Provider (IP) can be paid to work for an HSP customer:

A Santrax ID will be given to the IP for use in HSP's Electronic Visit Verification (EVV) system that records hours worked.
The customer's local DRS office will notify the customer of the IP's official start date.
The local DRS office will send the vendor authorization and Customer Service plan to the IP.

STOP NOTE: If the IP begins working for the customer before all the above situations occur, the IP will not be paid for those services.

Please note:

REVIEW AND PRINT the Provider Packet for HSP Customer Employment Checklist
Providers may also request a full paper version of the packet be mailed via USPS. To request a printed version be mailed, please contact the customer's local DRS office or MCO Care Coordinator.

1. Forms in this section are required: The forms in this section must be completed and returned to the Customer's local DRS office to process enrollment to become an Individual Provider.

Copy of a valid government issued photo ID.
Verification of your Social Security Number (The easiest way to verify this number is with the Social Security Card)
W-4: Federal Withholding Certificate, Spanish (external)
ILW-4: State Withholding Certificate, W4 Spanish (external)
Form I-9: Employment Eligibility, I9 Spanish (external)
- The IP must complete page 1
- The Customer (or representative) must complete page 1

If you are currently an ACTIVE IP and applying for a different HSP Customer, please only submit the documents below:

Verification of Social Security Number and a valid government issued photo ID.
Form I-9: Employment Eligibility, I-9 Spanish
IL488-2112: Individual Provider Standards, IL488-2112 Spanish
IL488-1413: HSP Provider Agreement, IL488-1413 Spanish
L488-2252: Individual Provider Payment Policies, IL488-2252 panish

2. Direct Deposit or Debit Card Payment

If an IP wishes to receive payment by direct deposit or debit card, submit ONE of the following forms. Initial payment(s) are issued by paper check and will remain paper check unless a form below is submitted.
- Direct Deposit (preferred): C-95A Direct Deposit Form
- Debit Card: Illinois Debit MasterCard IL444-0800Spanish

3. Individual Provider Background Screening

Customers of the Home Services Program have the option to complete a background screening on new or potential Individual Providers via the Mind Your Business (MYB) Program. Completion of this screening is optional. It is of no cost to the Customer and the results do not need to be shared with your HSP Counselor.
- Mind Your Business (MYB) Flyer
- Mind Your Business (MYB) Form (Optional) | r2-21Spanish
As a condition of employment to a customer of the Home Services Program, all Individual Providers shall be enrolled in the Illinois Medicaid Program Advanced Cloud Technology (IMPACT). As part of enrollment in IMPACT, a background screening shall be completed. Below you will find additional information regarding the enrollment in IMPACT, as well as the mandatory background screening that will take place. This is separate from the optional Mind Your Business (MYB) option listed above.
- Side Letter and Communication Regarding IP Background Screening Policy

4. The forms in this section should be read in their entirety and saved for future reference:

Versions: ~~3/25/2020, 4/10/2020, 4/17/2020, 5/14/2020, 1/14/2021, 2/9/2021, 2/18/2021, 3/24/2021, 4/1/2021, 1/2022,02/2023~~, 09/2023