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  3. General Provider Enrollment Requirements

General Provider Enrollment Requirements 

Provider Enrollment Application Information and Forms

Transportation Providers Only

Requirement To Participate

The general requirement to participate is the completion of an Illinois Department of Healthcare and Family Services Provider Enrollment Application and Agreement for Participation. Additional information may be required, such as:

Some provider types have the option of designating payment to an alternate payee. Completion of the designate of alternate payee form by both the provider and the payee is required.

Medical claim forms, with the exception of the UB92, are supplied to the provider when the department receives the Provider Forms Request HFS 1517 (pdf) or you can complete the online form request. Providers are requested to order a three-month supply of forms.

Provider application forms are also available by writing to:

Illinois Department of Healthcare and Family Services
Provider Participation Unit
P.O. Box 19114
Springfield, IL 62794-9114

Telephone inquiries should be directed to 217-782-0538.

E-mail: Provider Participation Unit

Long Term Care Facilities

The Illinois Department of Healthcare and Family Services, Bureau of Long Term Care, Enrollment/Certification Unit sends appropriate enrollment documents to long term care facilities interested in participating in the Medical Assistance Program. To request enrollment information please write to:

Illinois Department of Healthcare and Family Services
Bureau of Long Term Care
201 South Grand Avenue East
Springfield, Illinois 62763-0001

Telephone inquires should be directed to 217-782-0545 or 217-782-0557.