Registration for new entities in the CSA Tracking System

Registration for new entities in the CSA Tracking System need to answer and submit the following information to DHS.DMHGrantApp@Illinois.gov

1. Provider Common Name
2. Provider Legal Name
3. Provider FEIN (no dashes or spaces):
4. Provider DUNS # (no dashes or spaces):
5. Provider County
6. Provider Address
7. Provider City
8. Provider State
9. Provider Zip with 4-digit extension:
10. Is Billing Address Different?
11. Billing Address:
12. Director Name:
13. Degree(s):
14. Title:
15. Primary email:
16. Business Phone Number (no dashes or spaces):
17. Fax Number:
18. DHS Region:
19. House District Number:
20. Senate District Number:
21. Congressional District Number:
22. Chicago Community Area:
23. Taxpayer Certification Type: 

    Choices:

    • Corporation
    • Estate/Trust
    • Governmental Unit
    • Individual
    • LLC - C
    • LLC - D
    • LLC - P
    • Medical Corporation
    • Nonresidential
    • Partnership
    • Pharmacy - Non-corp
    • Pharmacy - Funeral Home/Cemetery
    • Sole Proprietorship
24. Additional Provider Contact Information:
    1. Name
    2. Title
    3. Address (If different from above)
    4. Phone # (no dashes or spaces):
    5. Email

Once your information is entered in the CSA Tracking System, it will automatically send you an invitation code to register.

Additional instructions for registering for CSA can be found at https://www.dhs.state.il.us/page.aspx?item=61069.