Provider Enrollment Application Information and Forms

• Letter to Providers (pdf) (html)
• Letter to DME Providers (pdf) (html)
• Letter to Pharmacy Providers (pdf) (html)
• Provider Enrollment Application - HFS 2243 (pdf)
• Instruction for HFS 2243 (pdf)
• Agreement for Participation - HFS 1413 (pdf)
• Hospital, Professional School or Group Practice as Alternate Payee Form - HFS 2307(pdf)
• Power of Attorney - HFS 2306 (pdf)
• MCH Primary Care Provider Agreement HFS 3411A (pdf)
• Advance Practice Nurse (APN) Certification and Collaborative Agreement HFS 3411C (pdf)
• IRS Request for Taxpayer Identification Number and Certification-Form W-9

Transportation Providers Only

• Letter to Transportation Providers (pdf) (html)
• Provider Enrollment Application - HFS 2243 (pdf)
• Instruction for HFS 2243 (pdf)
• Transportation Agreement for Participation HFS 1413T (pdf)
• Non-emergency Transportation Fingerprint Form HFS 3819 (pdf)
• IRS Request for Taxpayer Identification Number and Certification-Form W-9

Illinois Department of Healthcare and Family Services offers our Provider Enrolling Forms for download in Portable Document Format (PDF).

You will need Adobe´s Acrobat Reader® to view or print these files. If Acrobat Reader is not already installed on your computer, click on the icon below for a free Download. Then follow the instructions to install the program.

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:

• Medical license/certification
• Disclosure of ownership
• U.S. Department of Health and Human Services letter of certification

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) / HFS 1517A (pdf) Form 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.