Waiver Provider Agreement Instructions for Individual Professionals (HFS 1413A)

Read Carefully - Healthcare & Family Services (HFS) will return incomplete or inaccurate documents.  You will be notified by email to correct errors on your application.  When correcting errors, you must resubmit entire enrollment application packet.

  1. First Line: Enter the legal name of the professional. The legal name MUST be the same as on the provider enrollment application.
  2. Second Line: Enter Social Security Number (SSN). The SSN MUST be the same as on the provider enrollment application.
  3. Third Line: Always enter "DHS Division of Developmental Disabilities."
  4. Fourth Line: Always enter "DD Medicaid Waivers."
  5. Carefully read paragraphs 1 through 18 of the agreement.
  6. No information is required for #15 for individual professionals.  Do not put in agency information.
  7. Right after paragraph 18, there is a blank space in the paragraph that says "This agreement becomes effective."  Enter the first day of the month in which services were provided or will be provided.If no date is entered, DHS will enter the month that the application was received. This could cause billing rejection for services provided prior to this date.
  8. The agreement must have an original signature of the individual professional and the Social Security Number. DO  NOT use agency FEIN where you are employed.All forms that do not have the signature and Social Security Number will be returned by Health Care and Family Services (HFS).
  9. Do not enter any information into the box "FOR STATE AGENCY USE ONLY."

Note:  You must include a copy of the Waiver Program Provider Agreement HFS 1413a form with EACH Provider Enrollment Application HFS 2243. 

Any enrollment in the Illinois Medical Assistance Waiver Program requires the HFS 1413a, HFS 2243 and the W-9.  All information must be typed or printed and must be legible. To ensure prompt payment, this enrollment form, in addition to HFS 2243 and the W-9, must be completed and submitted before any services billed by the provider will be reimbursed by the Illinois State Comptroller. 

Note:  A new HFS Form 1413A must be completed when a change of ownership, legal name, Federal Taxpayer/Employer Identification Number (FEIN), or Social Security Number (SSN) occurs. 

Please Email or fax the completed enrollment application packet to:

Department of Human Services
Division of Developmental Disabilities
Medicaid Waiver Enrollment
319 E. Madison Street, Suite 3M

Fax:  (217) 558-2799

Email:  DHS.DDDMedProv@illinois.gov