Independent Provider - Directly Reimbursed

How do I enroll?

1. You are required to have a National Provider Identifier Number (NPI). If you do not have an NPI number, please complete the application on the National Plan and Provider Enumeration System website.
2. You must complete an online application to enroll as a Medicaid Provider using the IMPACT provider enrollment system.  You must enroll as an Individual Sole/Proprietor in IMPACT.  Please visit the DHS/DDD IMPACT page for additional information that is specific to enrolling as a DDD Waiver provider. After submitting an IMPACT application, please email Provider Enrollment the IMPACT application ID to ensure that the application is reviewed by a DDD Provider Enrollment Specialists.

3. If you will be submitting billing directly to DHS/DDD, the following documents must be submitted to Provider Enrollment:

   Department of Human Services
   Division of Developmental Disabilities
   600 East Ash Street, building 400, Mail Stop 2 South

   Springfield, IL 62706

   Attention: Provider Enrollment

   • IRS W-9 form.  Please review the IRS W-9 Guidelines before submitting the W-9.  Inaccurately completed W-9s could result in significant delays in the enrollment process.
   • Provider Information Form (IL462-1246)
   • FTP Registration Request Form 
   • Community Provider User ID and System Access Request (pdf)  (IL444-2022)

Important Resources for Requirements