Individual Provider IMPACT Form Instructions

The following is a guide to assist Individual Providers to correctly complete the IMPACT Individual Provider Enrollment Form and the Notice of Waiver Program Provider Agreement.

  1. Personal Assistant (PA)
  2. Certified Nursing Assistant (CNA)
  3. Licensed Practical Nurse (LPN) and Registered Nurse (RN)

IMPACT Individual Provider Enrollment Form (IL488-2263)

  • ALL Individual Providers are required to complete Section A of the IMPACT Individual Provider Enrollment Form
  • Personal Assistants and CNAs are required to complete Section A & B of the IMPACT Individual Provider Enrollment Form
  • LPNs and RNs are required to complete Section A & C of the IMPACT Individual Provider Enrollment Form
  • If you are an Individual Provider who provides more than one service type, please select your highest discipline.
    • Ex: You are a PA and a CNA, please follow the requirements and complete the form based on the highest discipline selected.
  • LPNs and RNs must provide a valid License Number to show they are certified.
  • NPI* (National Provider Identifier) is required for all LPN and RNs to be enrolled in the IMPACT System.

IMPACT Waiver Program Provider Agreement (IL488-2262)

  • ALL Individual Providers must print full legal name, last 4 digits of SSN, sign and date IL488-2262.
  • CNAs*, LPNs, and RNs must also include their NPI number.

Personal Assistant (PA)

  1. Individual Provider Information
    1. Please complete all of your basic information in Section A.
    2. Personal Assistants can leave the following blank:
      1. Application ID (For Office Use Only)
      2. License Number (For LPN/RN Only)
      3. NPI (For CNA*/LPN/RN Only)
  2. Provider Questionnaire for PA
    1. Please respond to all questions in Section B.
    2. If you are unsure of how to answer any of the questions, please respond with N/A under Comments.
  3. Provider Questionnaire for CNA/LPN/RN Skip Section C.

Certified Nursing Assistant (CNA)

  1. Individual Provider Information
    1. Please complete all of your basic information in Section A.
    2. CNAs can leave the following blank:
      1. Application ID (For Office Use Only)
      2. License Number (For LPN/RN Only)
  2. Provider Questionnaire for PA
    1. Skip Section B.
  3. Provider Questionnaire for CNA/LPN/RN
    1. Please respond to all questions in Section C.
    2. If you are unsure of how to answer any of the questions, please respond with N/A under Comments.

Licensed Practical Nurse (LPN) and Registered Nurse (RN)

  1. Individual Provide Information
    1. Please complete all of your basin information in Section A.
    2. LPN/RN can leave the following blank:
      1. Application ID (For Office Use Only)
  2. Provider Questionnaire for PA
    1. Skip Section B.
  3. Provider Questionnaire for CNA/LPN/RN
    1. Please respond to all questions in Section C.
    2. If you are unsure of how to answer any of the questions, please respond with N/A under Comments.

PLEASE NOTE:

National Provider Identifier (NPI):

If you are a CNA*/LPN/RN applying for a NPI number, the online application at https://nppes.cms.hhs.gov will require the entry of Taxonomy Code to process your request. The following Taxonomy Codes are recommended based on your Provider Type:

  • CNA: 376K00000X
  • LPN: 164W00000X
  • RN: 163W00000X

*NOTE: A NPI is optional for CNA's at this time and only required if you currently have one.