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Elizabeth M. Whitehorn, Director

Electronic Signature

Electronic Signature Agreement - ESA INSTRUCTIONS 

The Electronic Signature Agreement (ESA) is used to link an IMPACT login account with an approved Illinois Medicaid enrollment in IMPACT.  Providers should use this form to request access to view, maintain, and modify the enrollment.  Please review the following instructions carefully for guidance to complete and submit the ESA.

NOTE – If you have not logged into IMPACT since March 2022, you will need to create a new ILogin User ID. Instructions to create a new User ID can be found at Presentations and Materials | HFS under IMPACT Sign ON.

To access a provider's enrollment in IMPACT, please complete the ESA form and e-mail to IMPACT.HELP@illinois.gov with "ESA" or "Electronic Signature Agreement" in the subject line. 

NOTE: The ESA is a pdf fillable form and can be digitally signed. Click here for instructions to create a digital signature.

You will receive an email when the ESA has been processed. Once you receive the approval email, the requested enrollment should be viewable in the provider drop down the next time you log into IMPACT.