Note: It is important that you complete a separate HFS 2243 with the appropriate provider type for each waiver under which you will be providing services.
Complete this section only if there is a change of ownership, FEIN or name.
Not Applicable at time of enrollment. Payee information will be accepted on each bill for service.
This section must be completed in its entirety. The Agreement must have an original signature of the individual, or if a business entity, an authorized person. You must also print the name of the signer legibly.
Provider handbook box is not applicable. Click on this link for the: Provider Waiver Manual
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
IDHS Office Locator
IDHS Help Line
© 2020 Illinois Department of Human Services