New applicants, inactive providers, and/or providers that have not worked within the past 11 months, the following documents MUST be completed and submitted to the local DRS office to be considered for HSP Customer employment.:
Required documents to be sent back to the
local DRS office are listed in this table. |
Does the Customer sign? |
Does the Provider sign? |
| Copy of 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 |
|
YES! |
| ILW-4: State Withholding Certificate |
|
YES! |
| Form I-9: Employment Verification |
YES! |
YES! |
| IL488-2112: Individual Provider Standards |
YES! |
|
| IL488-1413: HSP Provider Agreement |
|
YES! |
| IL488-2252: Individual Provider Payment Policies |
YES! |
YES! |
| IL488-2262: Waiver Program Provider Agreement |
|
YES! |
| IL488-2263: IMPACT Enrollment Form |
|
YES! |
Form and Document definitions:
Copy of a Photo ID: Valid government issued photo ID.
Federal and IL W-4: These forms are used by the Illinois Department of Revenue and the IRS to collect information about your tax status and your withholding requests. The local office cannot help in completing these forms. If you need help with these forms, please contact a tax consultant.
Form I-9: The Provider will complete page 1. The Customer (as the Provider's employer) will complete page 2 after the Customer has received acceptable documents, listed in the instructions, from the Provider. Additional instructions can be found at https://www.uscis.gov/i-9, or can be printed at your local DRS office.
The most common answers to required documents for List B AND List C below:
List B - Identity
- Document Title: "Driver's License" or "State ID"
- Issuing Authority: "State of Illinois"
- Document Number: (DL or ID # from card)
- Expiration Date: (Expiration from DL or ID card)
List C - Employment Authorization
- Document Title: "Social Security Card"
- Issuing Authority: "Social Security"
- Document Number: (Social Security #)
IL488-2112 - IP Standards: This form establishes the work relationship with the Customer and the Customer's signature verifies that all information is correct.
IL488-1413 - Provider Agreement: This form establishes agreements between the Provider and the HSP Program as well as what service type(s) you will be providing to the Customer.
IL488-2252 - IP Payment Policies: This form provides important policies, rules and information concerning payments and potential fraud issues. Customer and Provider signatures are required.
IL488-2262 - Waiver Agreement & IL488-2263 - IMPACT Enrollment: You must enroll in the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system to be an eligible Medicaid Provider.
C-95A - Direct Deposit: If you would like direct deposit into an account at a financial institution, complete this form and return to:
- DHS/Expenditure Accounting Debit Card Project,
100 S Grand Ave E, 1st FL
Springfield, IL 62762
IL488-0800 - Debit Card: If you wish to receive payment through a debit card, please complete this form and return to the address listed on the document.
IL488-2399 - Report of Injury to a Provider: Please request this form from your local office or from the DHS Website and return within 24 hours of a work-related injury. Complete this form and return to the address stated on the document.
MYB Background Check: This form is optional. The Customer can request a background check for the Provider and must submit the form to the address listed on the document. Please allow up to 7 days for MYB to process and return a report.
