Electronic Signature Agreement - ESA INSTRUCTIONS DRAFT

The Electronic Signature Agreement (ESA)is used to link an IMPACT login account with an approved Illinois Medicaid enrollment in IMPACT.  This allows one to access an IMPACT application and to view, maintain, and modify the enrollment.  Please review the following instructions carefully for guidance on how to complete and submit the Electronic Signature Agreement.

In order to access an individual's Impact enrollment, you will populate boxes 2, 3, and 5 -          

• Box 2 – list the individual's name and NPI number
• Box 3 – the individual will sign and date
• Box 5 – list the Impact login account that you wish to use to      access the individual's Impact enrollment

In order to access an organizational or business enrollment on Impact, you will populate boxes 1, 4, and 5 –

• Box 1 – list the business name, tax ID, and NPI
• Box 4 – signature of the business owner or managing employee with date
• Box 5 – list the Impact login account that you wish to use to access the business's Impact enrollment

• Individual Provider Form 
• Organizational Provider Form 
  

Once complete, the Electronic Signature Agreement should be emailed to IMPACT.HELP@ILLINOIS.GOV.  Please put "ESA" and the enrollment NPI or Tax ID number in the subject line of that email.

An email will be generated and sent once the ESA has been processed.  After receiving the email, log into IMPACT to see the requested enrollment populated into the provider drop down.