XI. Appendices

DD Rates Charts

  1. Current Rate Chart  (Effective July 1, 2019)

Rights

  1. Choice of Supports and Services (English Version)  (IL462-1238)
  2. Choice of Supports and Services (Spanish Version)  (IL462-1238S)
  3. Release of Information (English Version) (IL462-1214)
  4. Release of Information (Spanish Version) (IL462-1214S)
  5. Rights of Individuals (English Version) (IL462-1201) 
  6. Notice of Individual's Right To Appeal (English Version) (IL462-1202)
  7. Notice of Individual's Right to Appeal (Spanish Version) (IL462-1202S)

Authorization/Prior Approval/Termination For Individuals

  1. Application for Individual Service Authorization (IL462-1248)
  2. Application for 60D CILA Support Services (IL462-4425)
  3. Application for 60D CILA Support Services Instructions  (IL462-4425)
  4. Individual/Guardian Information Form (IL462-2026)
  5. Bedhold Extension Request (IL462-2027)
  6. Medicaid Waiver Therapy Prior Approval Request (IL462-1302)
  7. Adaptive Equipment/Assistive Technology/Home & Vehicle Modification Request (IL462-1301)
  8. Service Termination Approval Request (IL462-2028)
  9. Crisis Information Funding Request (IL462-0140)

Provider Information/Enrollment

  1. Instructions on How To Obtain Your National Provider Identification Number (NPI)
  2. Medicaid Waiver Provider Enrollment Instructions (HFS 1413, HFS 2243, W9)
  3. Waiver Provider Agreement Medical Program (HFS 1413A)
  4. Instructions for HFS Form 1413A
  5. Provider Enrollment Application (HFS 2243)
  6. Instructions for HFS Form 2243
  7. Provider Types and Categories of Service
  8. Payee Designation/Authorization  (IL462-1180)
  9. Authorization for Background Check (CANTS) (CFS 689 - English Version)
  10. Authorization for Background Check (CANTS) (CFS 689S - Spanish Version)
  11. Request for Taxpayer Identification and Certification (IRS W-9)
    • All payee entities (including individual transportation providers and all other professionals, agencies and companies that plan to be reimbursed directly by the Illinois State Comptroller) must complete this U.S. Internal Revenue Service form.
    • The legal name and FEIN/FTIN or SSN on the W9 must match the name and FEIN/FTIN or SSN on the provider enrollment application (HFS 2243 and on the Provider Agreement (HFS 1413A).
  12. Provider Information Form (IL462-1246)

Billing/Documentation

  1. Correcting Individual Case Information and Rejected Fee-For-Service Bills
  2. DD and MH Fee-For-Service Programs - Request For Payment - Billing By Provider - Hourly  (IL462-1178)
  3. Instructions for IL462-1178 - Hourly
  4. DD and MH Fee-For-Service Programs - Request For Payment - Billing By Provider - Per Diem (IL462-1179)
  5. Instructions for IL 462-1179 - Per Diem
  6. DD and MH Fee-For-Service Programs- Request For Payment - Billing By Provider - Per Event (IL462-1177)
  7. Instructions for IL462-1177 - Per Event
  8. Day Program Daily Attendance Record (IL462-1303)
  9. Day Program Monthly Attendance Summary (IL462-1304)
  10. HBS Service Agreement (IL462-2029)

Other

  1. Notice of DHS Community-Based Services (HFS 2653)
  2. Instructions for HFS 2653
  3. Redetermination of Medicaid DD Waiver Eligibility (IL462-0952)