Payee Address Verification Tool

Payee Address Verification Form

Please provide your current payee name, address, facility number and FEIN to the Division of Developmental Disabilities (DDD) at the address indicated below. When changes occur, please notify the DDD in writing of any updates to this information as soon as possible to ensure proper payee information is being used for Training Reimbursement.

Note: Do not submit this form with each Staff Training Reimbursement Request. Only submit this form when the payee information changes.  Please submit to:

Department of Human Services
Division of Developmental Disabilities
319 East Madison, Suite 2K
Springfield, Illinois 62701

For an ICF/DD or SNF/PED

1. Provider Name:

   Provider Number:

   Facility Number:

   ---

   Payee Name:

   Payee FEIN Number:

   Payee Address:

2. For An Agency

   Agency Name:

   Agency Number:

   ---

   Payee Name:

   Payee FEIN Number:

   Payee Address: