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Elizabeth M. Whitehorn, Director

Electronic Signature

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.

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

To gain access to an Individual Provider’s enrollment in IMPACT, ONLY the following line items will need to be completed.

  • Individual Name and NPI – found on the second line of the ESA form.
  • Individual Signature – the individual provider who is granting access should sign and date here.
  • Requestor’s IMPACT USER ID – the email/USER ID that was created to access IMPACT should be entered here and then dated. Please note, this is the IMPACT User ID for the individual requesting access.

To gain access to Facility, Organization or Business enrollment in IMPACT, ONLY the following line items will need to be completed.

  • Employer or Employing Entity Name – the facility name, EIN and NPI the IMPACT user is requesting access to will be listed on this line.
  • Employing Entity Signature – the business owner or managing employee should sign date on this line.
  • Requestor’s IMPACT USER ID – the email/USER ID that was created to access IMPACT should be entered here and then dated. Please note, this is the IMPACT User ID for the individual requesting access. 

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.