DDD Provider Email List

First Name: *

Last Name: *

Email:

I Am A... (check all that apply)

CFO
QIDP
Program Staff
Self-Advocate
COO
PSW
Administrative Assistant
Executive Director
DSP
RN/LPN
Parent/Guardian
Other (please specify below)

Other Titles:

Address: *

City: *

State: *

ZIP: *

County:

Region:

Phone:

Fax:

For Agencies (only complete if applicable)

Agency Name:

FEIN (9 digits):

Provider/Agency ID (4 digits):

Trade and/or Advocacy Group Associations (check all that apply)

Don Moss & Associates
Institute on Public Policy for People with Disabilities
Illinois Council on Developmental Disabilities
Illinois Association of Rehabilitation Facilities
The Arc of Illinois
McManus Consulting
Illinois Self-Advocacy Alliance
The Center for Developmental Disabilities Advocacy and Community Supports
Not Applicable
Other (please specify below)

Other Associations:

Residential Services Provided (check all that apply)

Child Care Institution (CCI) 19D
Child Group Home (CGH) 17D
Community Integrated Living Arrangement (CILA) 60D & 65H
Community Living Facility (CLF): Waiver, 16 or less 67D
Community Living Facility (CLF): Non-Waiver, 17 or More 67E
Community Living Facility (CLF): Out-of-State 67O
Special Home Placement (SHP) 41D
Supported Living Arrangements (SLA) 42D
Intermediate Care Facilities for Individuals with DD (ICF/ID) Billed Through HFS
Medical Complex Facilities for persons with DD (MC/DD) (Formerly SNF/PED) Billed Through HFS

Day Program Services Provided (check all that apply)

Adult Day Care 35U
At-Home Day Services (CILA Only) 37U
Community Day Services (Formerly DT) 31U
Other Day Program 30U
Regular Work 38U
SODC Community Day Training 31S
Supported Employment (Individual & Group) 39U & 39G
ICF/DD Day Training Billed Through HFS

Home Based Services Provided (check all that apply)

Bogard Specialized Services 75 & 76 Series
ISSA Case Mgt 50D
Personal Support 55D
Self Directed Assistance 55A
Mental Health Service Facilitation 69B
Behavior Intervention 56U
Counseling (Individual & Group) 57U & 57G
Therapy (Individual & Group) 58U & 58G
Occupational Therapy 52O
Physical Therapy 52P
Speech Therapy 52S
Adaptive Equipment 53E
Assistive Technology 53T
Home Accessibility Modification 53H
Vehicle Accessibility Modification 53V
Respite - In Home (Grant Award) 87D
Residential Respite 89D

Grant Services and Supports (check all that apply)

Dental Services Grant 400
Epilepsy Services Grant 250
ISC Program Grant 500
PAS Program Grant 780
Respite - Group Grant 880

Special Project Grants 450 (check all that apply)

Autism Grant 450
Best Buddies Grant 450
Family Advocate Grant 450
Latino Outreach Grant 450
Lifespan Grant 450
Special Olympics Grant 450
Transitions Grant 450
Equip for Equality Grant 450

Other Services

Other Services (please specify below)

Other Services: