Il provider certification: Fill out & sign online

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Click ‘Get Form’ to open the il provider certification in the editor.
Begin with Part A: Applicant Information. Fill in the legal name of your agency, any 'Doing Business As' names, and provide a website address if applicable. Ensure all fields are completed accurately.
Proceed to Part B: Organizational Information. Mark the appropriate legal structure of your agency and list directors or officers as required. Attach necessary documentation for verification.
In Part C: Financial Information, enter your fiscal year details and provide your Federal Employer Identification Number (FEIN) or Social Security Number as needed. Attach a completed W-9 form and other financial documents.
Complete Parts D through H by providing information on computer capabilities, business practice history, service information, personnel policies, and certifications. Make sure to attach all required documents as specified.

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