A Professional who is Reimbursed Via Other Means

You must submit the following forms:

• Payee Designation/Authorization Form (IL462-1180)

  The Payee Designation/Authorization Form should be kept for your records for audit purposes.  The Department of Human Services does not require a copy of this document and does not retain this form for our records.

If not enrolled for DHS billing through the Reporting of Community Services (ROCS) system, the billing agency, group practice or limited liability corporation (LLC) complete the following forms:

• 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 

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

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

Please see web site on National Provider Identification Number

Important Resources for Program Requirements