Provider Connections

Changes & Additions

The following are options for CBO Enrollment changes and additions:

Changes and Additions CANNOT BE EMAILED due to sensitive information. They must be mailed or faxed.

All changes for specialist level providers and others enrolled in the CBO must also be changed in IMPACT.
Please visit the IMPACT webpage for more information.

Name changes

Individuals who have had a legal change in their name must change their name in the credential and enrollment systems for reimbursement of services to continue without disruption. To do this click on the name change link below and download/complete the EI Service Matrix Form and W-9 Form using the instructions that come with the documents. A copy of the legal document that verifies the name change must be included with this submission.

-Name Changes-

Address changes

Individual providers who need to make a change in their payment address for billing purposes must use the EI Service Matrix and W-9 form, contained in the link below, in order to make such a change.

Provider Agencies that need to make a change to the payment address for the agency for billing purposes must use the EI Service Matrix Form and W-9 form contained in the link below. Provider agencies must also include a typed list of all EI providers employed with the agency that are affected by the address change.

Individuals who work for an agency or agencies who just have a personal address change that is not tied to billing may send an email to providerconnections@wiu.edu or fax the change to 309-298-3066.

-Address Changes-

Adding Individual Enrollment

Providers who are currently enrolled in the EI Central Billing Office through one or more agencies may enroll themselves as an independent/private provider using the forms contained in the link below. Only providers who are currently enrolled should use these forms for enrolling independently. If an individual provider terminates employment with the agency(s) in order to provide independent services a letter should accompany the forms indicating that the employment ended and the last date of employment. This allows Provider Connections to inactivate enrollment for agencies where providers are no longer employed.

-Adding Individual Enrollment-

Adding Agency Provider Status to an Established Agency

Individuals who are currently enrolled in the EI Central Billing Office independently and/or with another agency may enroll themselves as a provider for another agency using the forms contained in the link below.

Use the instructions provided to complete the documents appropriately.

-Adding enrollment to Established Agency-

Creating a New EI Agency Provider

Individuals that are currently enrolled in the EI Central Billing Office independently and/or with another agency who would like to create a new agency should use the forms contained in the link below. For example, individuals enrolled as independent providers using their social security number as the taxpayer ID# who wish to employ other providers must establish themselves as other than an individual provider,

OR

Agencies in which the agency name and FEIN has changed must complete the forms contained in the link below and attach a list of all provider enrolled to bill EI for that agency.

-Creating a new EI Agency-

Provider Connections

Contact Info

Provider Connections
Center for Best Practices in Early Childhood Education
Western Illinois University
1 University Circle
Macomb, IL 61455

Phone:  800-701-0995
Fax:  309-298-3066
Email: providerconnections@wiu.edu

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