State of Illinois
Department of Human Services - Office of Information Technology
COMMUNITY PROVIDER / EXTERNAL USER I.D. AND SYSTEM ACCESS REQUEST
IL444-2022 (R-05-16) Community Provider/External User I.D. and System Access Request
Printed by the Authority of Illinois - 0 - Copies
Page 2 of 2
Instructions for Completion
Action Requested: Select the type of request
• Add User - requests an New user be assigned an IDHS user ID for access IDHS program/application,data,
system, or other IT resource.
• Delete User - requests an IDHS user ID be deleted and unable access IDHS program/application,data,
system, or other IT resource.
• System Access Only - requests access be granted to IDHS program/application,data, system, or other IT
Community Provider Information:
• FEIN NUMBER: Input the Agency FEIN; this field is Required for an ID to be assigned.
• IGA/DSA Number: Input the Intergovernmental/Data Sharing Agreement (IGA/DSA) Number that permits
access to IDHS systems, data, and applications.
o Check with your Organization/Agency or contact the IDHS program area (i.e. DMH, FCS) to provide
you this information. An IGA/DSA must be on file for an ID to be issued
• Agency Number: For use by E-Cornerstone users only.
• Medicaid I.D.Number:
• Provider Name: This is a Required field for an ID to be assigned.
User Information: Of the individual to whom the ID will be assigned, deleted, or system access provided.
• Full Work Address: The work location of the owner of the ID.
• Work Email Address: This must be an individual ID used only by the owner of the ID.
o User IDs and Passwords cannot be shared per State and IDHS policy, as well as
Federal program regulations.
• Work Telephone: Include extension if applicable.
• IDHS ID: Used for System Access Only, include user's current IDHS ID. Otherwise, leave field
User System Access Requested:
• FTP - File Transfer Protocol. Provides access to submit/retrieve applicable data files.
• Mobius View - Direct access allows the user on-line viewing of reports generated by the IDHS Provider
Claims Section. Access restricted to reports for the community provider entered.
• e-RIN - Provides access to request RIN assignments for individuals receiving service from the communi
• MedScreen - Provides access to utilize the Department of Mental Health (DMH) Medicaid Screening Tool
• SIS On-line - Provides access to the DMH On-line System.
• Cornerstone - Provides access to the various programs included in the Cornerstone system.
• IES: Provides access to the Integrated Eligibility System
• DMH Jail Link - Provides access to cross-match information between DMH and jail facilities.
• FOID: Provides access to utilize the IDHS On-line FOID System. Approving Authority: OCAPS
• IDHS Provider Claims: Provides access to only those reports the community provider entered.
User Signature and Date: Signing the form indicates user agrees to abide by the conditions outlined in the security
Approval Signature Section:
All requests must be signed by the Community Provider/External Entity Executive Director and IDHS Program
Area Approving Authorities. IDHS program areas have access to the complete list of IDHS Approving Authorities.