Individual Sole Proprietor

How do I enroll?

  1. Apply for a National Provider Identification Number (NPI) on the National Plan and Provider Enumeration System 
  2. Send the following enrollment documents to DHS, Division of Developmental Disabilities:
    • EMAIL:
      Illinois Department of Human Services Division of Developmental Disabilities
      600 East Ash Street, Building 400, Mail Stop 2
      South Springfield, IL 6270
      Attention: Provider Enrollment
      • Copy of License or certificate
      • IRS W-9 form  - Carefully review the IRS W-9 Guidelines and complete the IRS W-9 form based on the tax classification of the organization and determine if any additional IRS forms or other supporting documentation needs to be submitted with W-9.
  3. AFTER, you receive notification that your IRS W-9 has been certified, submit an IMPACT Provider Enrollment application for the company:
    1. You, person sitting at the computer to complete the enrollment application, must create an IMPACT account on the IMPACT login page and  apply for approval for a Single Sign-On ID.  Please use the Single Sign-On ID PowerPoint Presentation found on the IMPACT Presentations and Materials page on the HFS website to complete this step. 
    2. When the Single Sign-On ID has been approved, return to the IMPACT login page and log into your account. There will be a blue IMPACT hyperlink located on the IMPACT home page under the 4 green boxes.  Click on the IMPACT hyperlink to access the IMPACT Provider Enrollment System. 
    3. Click on NEW ENROLLMENT.  On the next screen, select the Enrollment Type: 
      • Individual/Sole Proprietor
      • Regular Individual/Sole Proprietor or Rendering/Servicing Provider
    4. On the Basic Information page, select the Applicant Type Individual Sole Proprietor.
    5. Please use the Individual Sole Proprietor PowerPoint Presentation as a guide to complete the enrollment application.  The PowerPoint Presentation can be found on the IMPACT Presentations and Materials page of the HFS website. 
      1. The IMPACT application for the company must includes the following information:
        1. Associate Provider: DDD Billing Provide ID number 7094718
        2. Associate Billing Agent: DDD Billing Agent number 7094638
        3. Associate MCO Plan: DDD MCO Plan ID number 3000006
  4. Send an email to notifying DDD Provider Enrollment that you completed the IMPACT application and submitted the application for State Review. 
  5. The IMPACT system will send you an email notification when your IMPACT application has been approved. 
  6. Review the information on the Using ROCS webpage and contact the ROCS helpdesk for Technical Support.

Important Resources for Requirements