Integrus Group

EIDBI Provisional Licensure Intake

  • Screen your current DHS checklist readiness
  • Capture key identifiers and role details
  • Get routed into onboarding with next-step instructions

About 4-6 minutes to complete.

This form screens for current DHS checklist items. You do not need to upload full documents at this stage.

Questions? Contact Us

Back to EIDBI Provisional Licensure

Start Your Intake - EIDBI Provisional Licensure

Agency Basics

Basic information about your agency and primary contact.

Application and Claim-Readiness

Help us understand where you are in the application process.

Role and Ownership Screening

Information about your agency's ownership and controlling individuals.

Service Model and Staffing Snapshot

Tell us about your service delivery model and staffing.

Documentation and Policy Readiness

Help us understand your current documentation status.

Key Identifiers and Record Location

Your enrollment identifiers and where your records are stored.

Optional but strongly preferred

Optional Upload

Optional: Examples include a DHS notice, notarized Applicant Agreement, or Provider Hub screenshot.

1 file max. PDF, JPG, or PNG only. Max 10 MB.

Acknowledgments

Anything Else?