A Professional who is Reimbursed Directly as an Independent Provider

You must submit the following documents:

• 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 

You are required to obtain a National Provider Identification Number (NPI) to render services.

Please see web site on National Provider Identification Number

Send the completed documents to the address below:

Department of Human Services
Division of Developmental Disabilities
319 E. Madison Street, Suite 3M
Springfield, IL 62701
Fax:  (217) 558-2799

Attention:  Provider Enrollment

Important Resources for Program Requirements