A Professional who is Reimbursed Via Other Means

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

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

Important Resources for Requirements