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COMMUNITY PROVIDER / EXTERNAL USER I.D. AND SYSTEM (Lake Land College)

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The COMMUNITY PROVIDER / EXTERNAL USER I.D. AND SYSTEM (Lake Land College) form is 1 page long and contains:

  • 3 signatures
  • 11 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

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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 1 of 2
User Signature: Date:
Community Provider / External Entity Executive Director Signature: Date:
Add User Delete User ID System Access Only (ID Previously Assigned)Security Administrator
Action Requested
Community Provider Information (Please Print)
FEIN No. (Required):
Provider Name (Required):
IGA/DSA No. (Required):
Agency Number: Medicaid ID Number:
First Name: Last Name:
Full Work Address:
Work Email Address (must not be a shared email address):
Work Telephone (and extension if applicable): IDHS ID, if already assigned:
User Information
User System Access Requested
FTP
SIS On Line
FOID
Mobius View
Cornerstone
IDHS Provider Claims
eRIN
IES
Other (specify):
MedScreen
DMH Jail Link
To Be Completed for all Transactions Except "Delete User ID":
I understand that the use of the IDHS systems, software, programs, data, manuals, and facilities is intended for and
may only be used for the purpose of accomplishing the official business of the Illinois Department of Human Services.
I understand that Illinois statute and IDHS policy prohibit disclosure or discussion of any confidential IDHS information
without proper written authorization. I understand that I am personally responsible for all usage under my User ID
and I agree not to give my User ID or password to anyone. I further understand that system usage is logged and
my access to use the system may be denied or revoked by IDHS.
User Printed Name:
Approval Signatures (required)
Community Provider / External Entity Executive Director Name (printed):
IDHS Program Approving Authority's Name (printed):
Date:IDHS Program Approving Authority's Signature:
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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
resource.
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
provider.
• 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
disclosure statement.
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.
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COMMUNITY PROVIDER EXTERNAL USER I.D. AND SYSTEM (Lake Land College)

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Completed 23 March 2021

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