A Professional who is Reimbursed Directly as an Independent Provider

1. You must submit the following documents, Encrypted, to Janene.Vanbebber@illinois.gov or to the address below:

   Department of Human Services
   Division of Developmental Disabilities
   319 E. Madison Street, Suite 3M
   Springfield, IL 62701

   Attention: Provider Enrollment

1. • IRS W-9 form and Guidelines
   • Provider Information Form (IL462-1246) 
   • Community Provider User ID and System Access Request  (IL444-2022)
   • FTP Registration Request Form 
   • Copy of your license

2. You must obtain your National Provider Identification Number 

   
    

Important Resources for Requirements