Script for EI Application

Script	Image/Video
Provider Connections EI Credential Application Podcast	Title page
Applicants seeking Early Intervention Credentials need to submit the EI Credential Application. A listing of positions for which providers must be credentialed is found in Part I of the Application.	Still of Part I
To access the EI Credential Application, go to the Provider Connections website at www.wiu.edu/providerconnections. Select the red Credentialing tab, then click New Applicants. You will see links for the EI Credential Application and the CBO Enrollment Application.	Video of web page
Download the EI Credential Application and save it to your desktop. Please do not use previously printed copies since there may have been changes to the forms, making them obsolete. Print the downloaded application.	Video of downloading and application
The first page is a checklist for the EI Application. It is for your use and does not need to be returned. The second page is the EI Credential Application. The third page is the instruction sheet.	Still of checklist, Application & Instruction sheet
Application for Illinois Early Intervention Credential	Title page
On the Application for Illinois Early Intervention Credential page, print your full legal name. Next, enter your individual 10-digit NPI number. All specialist level providers must have a personal NPI (National Provider Identification Number).Please go to the Provider Connections' homepage for information about obtaining an NPI number. Enter your Home address (street address). Enter the last four digits of your social security number. Enter your city, state, and zip code, along with your phone and fax numbers. List the number or numbers of the Child and Family Connections, also known as CFCs , that you will serve. A listing of CFCs is found on the Provider Connections Website under Related Links, then Child and Family Connections. Write your home county and any email addresses in the appropriate spaces.	Video of application being completed
Part I: New Applicants Check the first box if you are reactivating a lapsed credential. Check the second box if you are a registered Division of Specialized Care for Children. Place a check in the space provided in front of the credentials for which you are applying. The application contains information regarding requirements for each credential. Be sure to include the necessary documentation with the application.	Video of application being completed
Part II: Early Intervention Verification All providers must complete this section. Sign and date the application.	Video of application being completed
Background Checks	Title
The following page contains information relating to the required background checks. Three background checks are conducted on each credentialed provider: A Child Abuse & Neglect Tracking System (also known as CANTS), a State Fingerprint-based background check, and a check of state and national sex offender registries. Provider Connections staff completes the Sex Offender Registries process. There is no need to pay a vendor for this service. Once you have been determined to be eligible for a credential, you will receive a fingerprint-based background check form. Take this form to an approved vendor. A link to approved vendors is found on Provider Connections’ Home Page. Please do not take it to a local law enforcement agency. The Illinois State Police reports that law enforcement agencies are not equipped to handle the fee transactions.	Still of background page and video of sex offender registries
Authorization for Background Check	Title
This form is for the Child Abuse and Neglect Tracking System or CANTS. Complete the name line, Last Name first, followed by the first name, and then the middle name. Enter the date of birth in month-month, day-day, and four-digit year format, such as zero one, zero five, 1960. Circle the appropriate gender. Print the appropriate race. Complete your current address. Check whether you are a new applicant, a renewing applicant, or reinstating a lapsed credential. If you have a credential number, list it in the appropriate space. List any addresses you have had in the last five years. List your maiden name and/or other names by which you have been known. Sign and date the form. Once this form is received, it is sent to the Illinois Department of Children and Family Services (DCFS) for processing. This takes between 6-8 weeks.
Consultation Verification Form	Title
Providers must document 240 hours of direct services for which they are being credentialed. This service must be provided to children ages birth to three with special needs and their families. The documentation must show that the individual participated in consultation with an appropriately experienced individual of the same discipline or Early Intervention service group. This experience may have taken place prior to entering the Early Intervention System. Providers may use more than one Consultation Verification Form to document one or more work experiences or practicums. The consultation shall be in compliance with any professional standards of the individual seeking the credential as determined and documented by the consultant.
Early Intervention Ongoing Professional Development Plan Format	Title
All credentialed providers except Service Coordinators and Parent Liaisons must complete and submit this form. New providers will not yet have an Early Intervention Credential Number and do not need to complete that line. Sign and date the form. Meetings must take place once a month with another specialist provider during both the temporary and full credential periods.
Ongoing Professional Development Documentation Form	Title
This is the form used to document the Professional Development meetings. Enter your name for Provider Name and the appropriate year on the year blank. Providers with a temporary credential may enter either “temp” or the calendar year in that space. Print your credential number in the appropriate space. List the date and the location of each meeting in the first two columns. Your peer will sign in the third column and enter her or his credential number. Credentialed Providers may meet with a specialist-level provider of any discipline. List the date of the meeting and the location. If meeting by phone rather than face-to-face, make note of that in the location blank. The other provider will sign the form and list the credential number. Seventy-five percent of meetings must take place to keep the credential. Each line must be signed. One signature followed by a vertical line is invalid documentation.
The remaining portion of the packet contains information from Rule 500, including provider qualifications for credentialing and enrollment. Please take the time to read any sections that apply to you.
Except in the case of assistants, the credential application must be accompanied by a Central Billing Office enrollment application, which is found on the same web page as the EI Credential application. Please make sure to include all documentation, such as transcripts, licenses, and Systems Overview Certificates. Appendix C of Administrative Code 500 contains the requirements for providers. Mail your application to Provider Connections. If your need technical assistance in completing your application, please call 1-800-701-0995. We’re here to help you.
Once the credential is received, it is reviewed for completeness and accuracy. If the application is complete, the status becomes “in process” and is entered into the credential database. If the application is incomplete or contains errors, it is returned to the applicant. The credentialing process takes approximately 6-8 weeks.