Get Waiver Program Provider Agreement For Participation In The Illinois ... - Www2 Illinois

Filling out the Waiver Program Provider Agreement is an essential step for providers wishing to participate in the Illinois Medical Assistance Program. This guide will walk you through the entire process, ensuring you complete each section accurately and efficiently.

Follow the steps to fill out the provider agreement effectively.

1. Press the ‘Get Form’ button to access the Waiver Program Provider Agreement. This action will open the document in your chosen editing interface.
2. Begin by entering your full legal name and any assumed names under which you operate. If applicable, include your HFS Provider Number in the designated field.
3. Next, provide the name of the Waiver Agency with which you are enrolled. This information is necessary for establishing your relationship with the agency.
4. Indicate the specific Waiver Program related to this agreement, ensuring that you select the correct program to avoid any issues with your application.
5. In the agreement terms, read each provision carefully. Acknowledge your compliance with the policy provisions, licensing standards, and regulations as stipulated in the document.
6. Document your understanding of civil rights and anti-discrimination laws by acknowledging your commitment to providing equal access to services.
7. If applicable to your type of service, complete the section detailing ownership interests. List each owner or stockholder who holds 5% or more of the company stocks, including their Social Security Numbers and percentage of ownership.
8. Review all completed sections for accuracy. Ensure you have inputted all necessary information and that it is truthful and complete, as any misinformation can lead to serious consequences.
9. Finalize the document by signing in the designated signature fields both as the Provider and in any corresponding spaces for the designated agency representatives.
10. Once you have filled out the form, you can save your changes, download a copy for your records, print a hard copy, or share it with relevant parties as needed.

Complete your Waiver Program Provider Agreement online today to ensure your participation in the Illinois Medical Assistance Program.