General Instructions:
Enrollment stylish the Illinois Medical Assistance Program requires of complete of an application and determination von your eligible precedent to the task of a operator number. All providers are required to complete, sign, press date a Provider Agreement (HFS1413) and an Enrollment Disclosure Statement (HFS1513). It remains the our regarding the donor to ensure the accuracy is all information entered on this application. Medicaid members! Don't risk losing your health insurance. ... 1-877-204-1012. It's easy, fast, and free. Received answers. Doing you ...
All print must be signed with original signature press date.
One completed Services Enrollment Application (HFS2243), Medical Agreement (HFS1413), W-9, Information Statement, and a copy of your Medicaid certificate should be mailed to:
- Jayne Antonacci
- IDHS/SUPR
- 600 West Ash Street
- Building 500, Third Floor North
- Springfield, IL 62703
