This window allows you to register as an administrator for a Medicaid provider.
Tip: If you are using a tax ID number to register, remember that tax ID numbers are validated against active payee numbers. If you have no active payees, use a different field to register - either enrollment date or license number.
You must enter provider information exactly as it appears on the Provider Information Sheet in order to register as a Medicaid Provider.
If you have previously registered as the Administrator for a Provider, and your registration is active, you will not be allowed to register again as an Administrator for the same Provider.
If you want to change your relationship with the business, review the instructions in the Change Your Business Relationship topic.
A Provider Business may have no more than 2 active administrators at any one time.
Warning: You are only allowed 5 attempts to register. If you are unsuccessful 5 times, your account will be locked and you will have to contact Network Services to unlock your account.
Review the Business Registration Overview for more information.
You must enter all required fields, and in the correct format. See below for a list of fields and validation rules.
Field Name |
Definition |
Validation Rules |
Field Type |
|
Provider Number |
the number assigned by HFS to the provider of services |
Required. Must match exactly the entry on HFS's Provider Database. |
Text Box |
|
Provider Type |
the number assigned by HFS that indicates the type of provider |
Required. Must match exactly the entry on HFS's Provider Database. |
Text Box |
|
Provider Name |
the name of the business |
Required. Must match exactly the entry on HFS's Provider Database. |
Text Box |
|
Provider Address |
the business address; should be the street address of the physical building rather than the mailing address |
Required. Address must be at least 3-characters in length. Certain special characters are not allowed. |
Text Box |
|
Second Provider Address Line |
additional business address information; may be the mailing address of the business |
Not Required. If entered, the address must be at least 3-characters in length. Certain special characters are not allowed. |
Text Box |
|
City |
the city where the business is located; must be the city where the physical building is located |
Required. City must be at least 2 characters in length. Certain special characters are not allowed. |
Text Box |
|
State |
the state where the business is located; must be the state where the physical building is located |
Required. Select an entry from the dropdown list. |
Dropdown Box |
|
ZIP |
the ZIP code of the physical building |
Required. Formats |
Text Box |
|
Business Phone Number |
the main phone number for the business |
Required. Formats |
Text Box |
|
Business Fax Number |
a fax number for the business |
Not Required. Formats |
Text Box |
|
Your Work E-Mail Address |
your work e-mail address, if you have one; may be your personal e-mail address |
Required. Must be a valid e-mail format. |
Text Box |
|
Your Work Phone |
your phone number at work; if you do not have a direct line, a phone number where you can be reached at work |
Conditionally Required if work extension is not entered. Formats |
Text Box |
|
Your Work Ext |
your phone extension number at work, if you have one |
Conditionally Required if work phone is not entered. If entered, must be numeric. |
Text Box |
|
Enrollment Date |
the enrollment date from the Provider Information Sheet |
Conditionally Required. If State Medical License Number and Tax ID Number are not entered, enrollment date is required. Formats |
Text Box |
|
State Medical License Number
|
the state license number issued to the provider by the State of Illinois |
Conditionally Required. If Tax ID Number and Enrollment Date are not entered, then State Medical License Number is required. Must be at least 5-characters in length. |
Text Box |
|
Tax ID Number |
the tax ID number of the business |
Conditionally Required. If State Medical License Number and Enrollment Date are not entered, Tax ID Number is required. Formats |
Text Box |
|
Tax ID Number Type |
the type of tax ID number you entered |
Conditionally Required. If Tax ID Number is entered, Tax ID Number Type is required. Select either FEIN or SSN. |