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Provider Agency Agreement
Illinois Department of Human Services
Provider Agency Agreement for Authorization to Provide Early Intervention Services
Note: The Provider Agency shall type or print legibly all information except for the signature.
The Provider Agency Agreement is for the sole use of an entity which either employs or contracts with
other Early Intervention certified individuals to provide Early Intervention Services.
This Early Intervention Service Provider Agency Agreement is entered into by and between the Illinois
Department of Human Services (DHS) as the Lead Agency for the Illinois Early Intervention Services
System and funder of the Early Intervention Program, (EI), and :
(Provider Agency Name)
Purpose of Agreement: The purpose of this Agreement is to establish the duties, expectations and
relationship between DHS and the Provider who makes service(s) available to eligible children and their
families according to the Illinois Early Intervention Services System Act, 325 ILCS 20/5 et. seq. (the Act),
Part C of the Individuals with Disabilities Education Act (IDEA) (20 U.S.C. Section 1431 et seq.) the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and EI administrative rules.
Definition of Provider Agency: The payee entity identified on the W-9 page of the Central Billing
Office Application under Business Name and Taxpayer Identification Number.
Definition of Child and Family Connections (CFC): The CFC is the system point of entry in a
designated geographic region that is responsible for providing access to the Illinois Part C Early
Intervention Services System, for providing service coordination services, and for maintaining the child’s
permanent EI Record for referred and eligible children.
Definition of Department of Human Services Central Billing Office (DHSCBO): The DHSCBO is an
entity designated by DHS for the processing of Early Intervention claims and for data collection.
In consideration of the Authorization to Bill DHS for the Provision of S