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Hfs2378h (Illinois)

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HFS 2378H (R-02-13)
State of Illinois
Department of Healthcare and Family Services
Department of Human Services
Instructions for Mail-In Application for Medical Benefits
(Esta solicitud está disponible en español.)
(This application is available in Spanish.)
Medical benefits are available to eligible persons who need help paying their medical bills.
This is NOT an application for cash assistance, food stamps, or the other programs listed on page 6 of these
instructions. If you want to apply for cash assistance or food stamps, contact your local Department of Human
Services (DHS) Family Community Resource Center (FCRC).
Voter's Registration Information
If you want to apply to register to vote, fill out the enclosed Illinois Voter Registration Application SBE (R-19) and
return it to your DHS FCRC or your local election official. If you would like assistance or need translation services,
contact your DHS FCRC. You may also call the Helpline at 1-800-843-6154, or 1-800-447-6404 (for TTY).
For information online, see www.dhs.state.il.us or www.elections.il.gov/
Note: Applying or declining to register to vote will not affect the amount of benefits you get from this agency.
WHAT MEDICAL SERVICES ARE COVERED?
WHERE CAN YOU GET THESE MEDICAL SERVICES?
You may go to any medical provider who accepts the HFS medical card.
WHEN WILL YOU KNOW IF YOU QUALIFY?
If you are applying because you have a disability, DHS will send you a notice to tell you if you are eligible for medical
benefits within 60 days of the date you apply. If you do not have a disability, the notice will be sent within 45 days.
WHAT IF YOU DISAGREE WITH THE DECISION?
If you are not satisfied with the actions taken on this application, you have the right to a fair hearing. You can ask for a
fair hearing by calling 1-800-435-0774 (TTY: 1-877-734-7429) or by writing to the Department at 401 South Clinton
Street, 6th Floor, Chicago, IL 60607. The call is free. Use this address only to ask for a fair hearing. DO NOT SEND
THIS APPLICATION TO 401 SOUTH CLINTON.
For more information call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free
Instructions 1
• medical transportation
• hospice care
• home health care services
• physical, occupational and speech therapy
• family planning
• medical equipment, supplies and appliances
• podiatry care
• help for alcohol and substance abuse
• chiropractic care
• shots and check-ups for children
• mental health care
• hospital care
• nursing facility care
• supportive living care
• doctor services
• prescription drugs
• audiology services
• care at clinics
• renal dialysis
• laboratory tests and x-rays
• dental care (limited services for adults)
• eye care
HFS 2378H (R-02-13)
INSTRUCTIONS: Read the application carefully and follow all instructions.
1.
2.
Sign the application.
3.
Attach copies of any required Forms A through H and documents to the application. Failure to submit required
forms or documents could result in denial of your application. See instructions pages 3 and 4.
Mail the application to your local DHS FCRC office. If you do not know the address visit the DHS website at
www.dhs.state.il.us or call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free.
4.
Medical benefits programs comply with all state and federal laws, rules and regulations pertaining to equal access
regardless of sex, race, disability, national origin, religion, or age. The State of Illinois is an equal opportunity
employer that practices affirmative action. The State of Illinois provides reasonable accommodations according to
Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.
To file a complaint of discrimination, contact any or all of these offices:
Illinois Department of Human Services (DHS)
Bureau of Civil Affairs
401 South Clinton Street, 2
nd
Floor
Chicago, Illinois 60607
Illinois Department of Healthcare
and Family Services (HFS)
EEO/AA Office
401 South Clinton Street, 5
th
Floor
Chicago, Illinois 60607
U.S. Department of Health and
Human Services (HHS)
Director, Office for Civil Rights
Room 506-F,
200 Independence Avenue, S.W.
Washington, D.C. 20201
Call
(202) 619-0403 (voice) or
(202) 619-3257 (TTY)
Instructions 2
For more information call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free
Complete pages 1 - 6 of the application. Depending on your situation, also complete the attached Forms A
through H. Be sure to mail all documents together. Answer questions completely and accurately. If you cannot
answer all of the questions, fill out as much as you can. If you need more space to answer questions, attach an
extra sheet. If you have questions, call your local DHS FCRC office or call
1-800-843-6154 (TTY: 1-800-447-6404). This call is free.
• Complete Form A if anyone applying for medical benefits has Medicare or other health insurance.
• Complete Form B if anyone applying is blind, has a disability or is age 65 or older.
• Complete Form C if anyone applying lives in or intends to move to a nursing home facility or a supportive
living facility, or receives or has applied for services through the Department on Aging Community Care
Program.
• Complete Form D if the person is transferring income and assets to spouse.
• Complete Form E if anyone applying is blind, has a disability or is age 65 or older and is employed or if a
responsible relative living with the person is employed. A responsible relative is a spouse or a parent of a
child younger than 18.
• Complete Form F if anyone applying is married, but does not live with his or her spouse.
• Complete Form G if the Social Security Administration has not yet decided if the person has a disability.
• Complete Form H (Rebate Form for All Kids or FamilyCare) if you are applying for a child or caretaker relative
including a parent who is already covered by health insurance or for whom you have arranged for health
insurance to begin soon.
HFS 2378H (R-02-13)
INFORMATION TO INCLUDE WITH THE APPLICATION
To get medical benefits, you must provide proof for some of the information you give. Please attach copies of the
following documents with this application. Include all that apply. Please see the information on the next page
about providing documents for U.S. citizens.
• Income - Send proof of each type of income listed on the application. If the person applying lives with his or her
spouse, include the spouse's income. This may include:
•
Copies of pay stubs for earnings and proof of tips received during the last month. If anyone is self-
employed, provide detailed business records that include income and expenses for the last month.
•
Copies of checks for the last month or award letters for Unemployment Benefits, Social Security Benefits
and Veteran Benefits.
•
Copies of checks for the last month or a support order for spousal or child support.
•
Proof of other income including income from trusts, pensions, rental property, etc. Also send proof of
expenses tied to rental income.
• Support Paid - To get credit for spousal or child support paid, provide proof of payments made in the last month.
• Proof of Pregnancy - If anyone applying for medical benefits is pregnant, provide a signed statement from her
doctor or health clinic that includes the date she is expected to deliver and the number of babies expected.
• Proof of Application for a Social Security Number - If anyone applying for medical benefits does not have a
Social Security Number, provide a signed statement from the Social Security Administration that application for a
number has been made.
• Medicare or Other Health Insurance - If anyone applying has Medicare or other health insurance, complete the
attached Form A or provide a copy (front and back) of the Medicare card or health insurance card. If anyone can
get free health insurance through a job or union, provide information about the plan and qualifications.
Instructions 3
For more information call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free
HFS 2378H (R-02-13)
INFORMATION TO INCLUDE WITH THE APPLICATION (cont.)
• Immigration Documents for Non-Citizens - If anyone applying for medical benefits is not a U.S. Citizen, provide
proof of their immigration status. Proof is a copy of any one of the following:
•
Alien Registration Receipt Card/Permanent Resident/Green Card (INS-3A); or
•
Passport with the following stamps or attachments: Arrival-Departure Record with the stamp showing
status (I-94), or Resident Alien form (I-151 or I-551), or Temporary Resident Card (I-688); or
•
A court ordered notice for Asylees; or
•
INS documents with an A-number; or
• Other proof of lawful immigration status.
Pregnant women and children under age 19 who do not have proof of their immigration status may still qualify for
medical benefits. However, you should provide proof if you have it.
Other adults who want medical benefits must provide proof of their immigration status. We will contact the U.S.
Bureau of Citizenship and Immigration Services to check their status. Adults must also have been in the U.S. for
at least five years. The state can cover medical care provided in an emergency for adults whose legal
immigration status can not be verified, or if they have been in the U.S. less than five years, only if they meet all
other medical program requirements.
• Documents for U.S. Citizens - For anyone who is a U.S. citizen and requesting medical benefits, provide one of
the following documents: U.S. Passport, Certificate of Naturalization (N-550 or N-570) or Certificate of Citizenship
(N-560 or N-561). If these are not available, provide one document from each of the two categories listed below:
Place of Birth
• Certified copy of birth certificate from the state or
county where the person was born;
• Final Adoption decree;
• Official military record that shows a place of birth;
or
• Papers showing the person was employed by the
U.S. Government before 1976.
and
Identity
• Driver's license;
• State issued ID card;
• School ID;
• U.S. Military ID;
• U.S. Military dependent card; or
• Other government ID
(issued by city, county, state or federal)
• For children under age 16, school or day care
records or a report card.
If you receive Medicare, SSI or Social Security Disability income, you do not need to provide proof of your
U.S. citizenship or identity.
• If you or your representative bring this application to your local FCRC office in person, or can come into the office
after sending the application in, please bring original or certified copies of citizenship and identity documents.
• If you mail in copies with this application, we may ask you to show the original documents at a later time.
Persons who are blind, have a disability or are age 65 or older, go to next page.
Instructions 4
For more information call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free
HFS 2378H (R-02-13)
INFORMATION TO INCLUDE WITH THE APPLICATION (cont.)
If anyone applying is blind, has a disability or is age 65 or older, provide proof of the following information if it applies.
• Age - If anyone applying for medical benefits is age 65 or older, provide proof of age. This may include a copy of
the person's birth certificate, Social Security records, passport or Veteran Administration records.
• Disability - If anyone applying for medical benefits has a disability, provide proof of disability and complete Form G.
If they get Supplemental Security Income (SSI), or Social Security Disability Insurance (SSDI) benefits, they do not
have to provide other proof of disability. If the person does not get SSI or SSDI benefits, provide a current medical
report.
• Employment Expenses - If anyone applying for medical benefits is employed, complete Form E. Also complete
Form E for an employed spouse or parent of a child under age 18 if they live together. We will deduct the following
from earnings if you provide proof of:
• Federal, State, or City income taxes,
• Social Security tax,
• Transportation to work expenses at the most reasonable rate. We allow 24 cents per mile if you use your
own car,
• Special tools and uniforms required for the type of work performed,
• Union dues, group life insurance premiums, group health insurance premiums and retirement plan with
holdings, if required as a condition of employment, and
• For persons with disabilities, special work expenses, such as special transportation to work or a
telecommunication device for the hearing impaired, that allow them to work. To be allowed as a deduction,
the expenses must be paid by the applicant and not be reimbursed by an agency or other person.
• Resources - Send proof of each resource listed on Form B. If the person lives with his or her spouse, include the
spouse's resources. This may include, but is not limited to, copies of current bank statements, certificates of
deposit, life insurance policies, vehicle titles, prepaid burial contracts, trust documents, property deeds, and
property tax bills.
• Resources and Income of Spouse - Provide proof of a spouse's resources and income, if anyone applying wants
to transfer resources or income to his or her spouse and the person applying:
• lives in or intends to move to a nursing home facility,
• lives in or intends to move to a supportive living facility, or
• receives or has applied for services through the Department on Aging's Community Care Program.
If any apply, complete Form D.
Instructions 5
For more information call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free
HFS 2378H (R-02-13)
OTHER BENEFIT PROGRAMS OFFERED BY THE STATE OF ILLINOIS
Instructions 6
For more information call 1-800-843-6154, (TTY: 1-800-447-6404). The call is free
IOCI 0441-12
You may also qualify for these programs:
• Home and Community Based Services - You or your family members may also qualify for one of the Illinois
home and community based services programs. These programs allow eligible individuals to either remain in their
own home or live in a community setting, rather than an institutional setting such as: a hospital, nursing home
facility, supportive living facility or intermediate care facility for the developmentally disabled. For more
information visit www.hfs.illinois.gov/hcbswaivers/
• The Low Income Home Energy Assistance Program (LIHEAP) helps qualified households pay for winter energy
services. The amount of the benefit depends on income, household size, fuel type and geographic location. For
more information, visit www.liheapillinois.com
• The Illinois Department of Human Services' Child Care Program provides low-income, working families with
access to quality, affordable child care. Parents can learn about childcare in their community and see if they
qualify for a subsidy by contacting their local Child Care Resource and Referral agency (CCR&R). Visit
www.ilchildcare.org or call 1-800-649-1884 to find your local CCR&R. The call is free.
Here are other medical programs in Illinois:
•
Veteran's Care offers access to affordable, comprehensive healthcare to veterans across Illinois. Veterans pay
an affordable monthly premium of $40 or $70 and receive medical, dental and vision coverage. For additional
information, please visit www.illinoisveteranscare.com or call 1-877-4VETS-RX (TDD: 1-877-504-1012). The
call is free.
• Health Benefits for Workers with Disabilities is a comprehensive healthcare program for employed persons with
disabilities. Working individuals between the ages of 16 and 64 may be eligible. To download an application, visit
www.hbwdillinois.com or call 1-800-226-0768 (TTY: 1-866-675-8440). The call is free.
• The Illinois Breast and Cervical Cancer Program (IBCCP) provides cancer screening and treatment for eligible
women 35 and older (younger women may be eligible in some cases). To find out if you qualify visit
www.cancerscreening.illinois.gov or call the Women's Health Line 1-888-522-1282 (TTY: 1-800-547-0466).
The call is free.
• The Illinois Healthy Women (IHW) program provides family planning and related services for women between 19
and 44 years old. To find out if you qualify, visit www.ihwillinois.com or call the Health Benefits hotline at
1-800-226-0768 (TTY: 1-866-675-8440). The call is free.
Print These Instructions
HFS 2378H (R-02-13)
APPLICANT - The applicant is usually the person filling out this form or who has someone complete the form for
them. The applicant can also be the parent, guardian or other relative a child lives with. The information you provide
on this application is confidential and may only be used for purposes directly connected with the administration of the
medical benefits programs. See Instructions 3 to 5 for a list of documents you may need to send with this application.
Other (please list)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Asian
Black or African American
White
Race (Mark all that apply)
Yes
No
Are you Hispanic or Latino?
Race / Ethnic Group (for information purposes only)
English
Spanish
Other (please list)
Language Preference
Zip
State
City
Address
Zip
State
City
Address
If you are living in a nursing home, list the two places you lived prior to moving to the nursing home. If you have not yet moved to
a nursing home, list the last two places where you lived prior to your current residence.
Other phone
number
Mailing Address
(if different than above)
Address (Please list Street, City,
State, Zip and County)
Daytime phone and
best time to call you
Name
(Last, First, Middle Initial)
Answer questions completely and accurately.
and facility name
the actual or expected discharge date
If the applicant is in a health care facility, enter the date of the
applicant's admission to the facility:
Case Number
Recycle any instruction pages
sent with this application.
AGENCY USE
ONLY
Date Received
Mail-In Application For Medical Benefits
State of Illinois
Department of Healthcare and Family Services
Department of Human Services
Social Security
Number
U.S.
Citizen
Wants
Medical
Benefits
Relationship
To Applicant
(wife, son, etc.)
Birth
Date
Sex
A. Name
(Last, First, Middle Initial)
Enter the following for the person applying for medical benefits and all persons living with them. You do not
have to give the Social Security Number or the U.S. citizenship status for a pregnant woman or anyone who
does not want medical benefits. Attach an extra sheet if more space is needed.
1. PERSONAL INFORMATION
1)
1)
Yes
No
Yes
No
Applicant
1)
M
F
2)
Yes
No
Yes
No
2)
2)
M
F
2)
3)
3)
Yes
No
Yes
No
3)
3)
M
F
4)
4)
Yes
No
Yes
No
4)
4)
M
F
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Page 1 of 17
HFS 2378H (R-02-13)
If no, enter the person's name:
B. For each person under age 18 applying for medical benefits, tell us about their parents. If a parent does
not live with the child, also enter the parent's address.
First Child's Name
Mother's full name:
SSN:
Mother's Employer:
Address
if other:
C. Is anyone applying a veteran or a spouse, child, widow(er) or parent of a veteran?
If yes, enter the person's name and relationship to the veteran:
D. Is anyone applying blind or have a disability?
If yes, enter the person's name:
E. Does everyone applying live in Illinois?
Address
if other:
Father's Employer:
SSN:
Father's full name:
Full-time
Part-time
Full-time
Part-time
Complete Form G if the Social Security Administration has not yet decided if the person has a disability.
Yes
No
Yes
No
Yes
No
2. PERSONAL INFORMATION (continued)
Page 2 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Mother's Employer:
SSN:
Mother's full name:
Second Child's Name
Mother's Employer:
SSN:
Mother's full name:
Third Child's Name
Full-time
Part-time
Father's Employer:
SSN:
Father's full name:
Address
if other:
Father's Employer:
SSN:
Father's full name:
Address
if other:
Full-time
Part-time
Address
if other:
Address
if other:
Full-time
Part-time
Full-time
Part-time
HFS 2378H (R-02-13)
Facility Street Address:
If yes, enter the person's name:
Name
City
1)
1)
State
1)
2)
3)
2)
3)
2)
3)
G. If anyone applying is not a U.S. citizen, enter their name. If the person has a valid Alien Registration
Number, enter it also. Send a copy of proof of the Alien Registration Number. See page 4 of the
instructions for more information.
Valid Alien Registration Number
Name
3)
2)
1)
3)
2)
1)
F. If anyone applying is a U.S. citizen, enter their name and the city and state where they were born. Send
proof of their identity and their citizenship. See page 4 of the instructions for more information.
If yes, you must complete forms B, C and D.
H. Does anyone applying live in a nursing home facility or supportive living facility?
Was the person a resident in the facility prior to 07/01/96?
Facility Name:
City, State,
Zip Code:
Facility Telephone
Number and Area Code:
If yes, enter the person's name:
I. Does anyone applying receive or has anyone applied for services through the
Department on Aging's Community Care Program?
If yes, enter the person's name:
J. Is this an application to pay bills for someone who has died?
Date of Death:
Yes
No
Yes
No
Unknown
Yes
No
Yes
No
2. PERSONAL INFORMATION (continued)
Page 3 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
HFS 2378H (R-02-13)
If yes, enter the person's name:
N. Is anyone applying covered by Medicare or other health insurance?
If yes, complete Form A.
If yes, enter the guardian's name:
K. Does anyone applying have a legal guardian?
Attach copy of guardianship papers.
,
If yes, enter the person's name:
L. Is anyone applying pregnant or has anyone been pregnant within the last 3 months?
due date or delivery date:
and number of babies expected or delivered:
If yes, do you want us to decide if they can get help to pay these bills?
M. Did anyone applying receive any medical service during the 3 months before the
month of this application?
If yes, list months:
O. Does anyone applying have a high cost medical condition?
Does the person have health insurance for the medical condition or can they get health
insurance through a recent employer or through a relative's policy?
If yes, enter the person's name:
P. Can anyone applying get free health insurance through a job or union?
,
.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
2. PERSONAL INFORMATION (continued)
Page 4 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
If yes, enter the person's name:
Yes
No
Q. Is anyone applying enrolled in the Illinois Comprehensive Health Insurance Plan
(ICHIP) program?
HFS 2378H (R-02-13)
Enter all money that anyone applying for medical benefits receives. If married and living with spouse, also
enter any money the spouse receives. If under age 18 and living with a parent, also enter any money the
parent receives. Attach proof. Enter the amount before deductions like taxes or insurance. Check all that
apply and enter details below:
If yes, enter the person's name who pays support:
Does anyone pay support for a person for whom they are legally responsible or for
whom there is a court order for support? Attach proof.
Amount paid: $
How often paid:
Court ordered:
4. INCOME AND BENEFITS
Contributions
Disability Benefits
Dividends or Interest
Veterans Benefits
Social Security
Other:
Unemployment Benefits
Royalties, Oil/Mineral Rights
Railroad Retirement Benefits
Pensions/Retirement Benefits
Farm Income
Worker's Compensation
Trust or Annuity Payments
Wages/Self-Employment
Alimony
Rental Income
Child Support
SSI
List additional income and
benefits not shown here:
Person Who Receives Income
1)
$
3)
3)
$
2)
2)
$
1)
Amount
Source of Income. If work,
enter employer's name.
3)
2)
1)
How
Often?
3)
2)
1)
If Social Security,
enter Claim Number
5. CHILD CARE
If yes, complete the following:
Do you or does anyone living with you pay for child care so they can work?
Child's Name
1)
3)
3)
2)
2)
1)
Care Giver Name
Monthly Amount
$
3)
$
2)
$
1)
Person Paying for Care
Yes
No
Yes
No
Yes
No
3. SUPPORT PAID
Page 5 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
HFS 2378H (R-02-13)
Read carefully, then sign and date the application below.
1. We will keep what you tell us private as required by law.
2. Some families have to make a payment each month for this health insurance. This payment is called a
premium. The amount of the premium depends on the family income.
3. Some families have to pay part of the bill when they visit the doctor, go into the hospital, or get a
prescription filled. These payments are called co-payments. The amount of co-payment depends on the
family income.
4. Some individuals have to incur medical expenses to qualify for a medical card. This is called a spenddown.
This is similar to a health insurance deductible.
5. You agree the state may seek reimbursement for services the state covered for your family if those services
should have been paid for by any other health coverage your family may have.
6. Be sure to answer the questions correctly. We may check all information on this form. You must help us if
we ask you to prove that your information is right.
7. We will not share any information about immigration of any person who does not have an Alien Registration
Number. We will verify the immigration status of any person if you gave us their Alien Registration Number.
To do that, we will check the number with the U.S. Bureau of Citizenship and Immigration Services (USCIS).
We may send USCIS other information such as copies of proof you sent of an Alien Registration Number
and the person's Social Security Number, if they have one.
8. You must tell your caseworker within 10 days if any of the following happens:
• Your income changes;
• The number of people in your family who live with you changes;
• You move or change your mailing address; or
• Someone who gets health benefits moves out of Illinois, dies, or goes to jail or prison.
9. If we pay medical bills for you, you give your right to collect medical support payments to the State of Illinois.
You must help us if we ask you to establish paternity or obtain medical support payments for members of
your family. You may not have to do this if you have a good reason not to. Your children can get health
insurance even if you do not help us when we ask you to help.
10. Anyone who misuses the health insurance card may be committing a crime.
I declare under penalty of perjury that I have read all statements on this form and the information I give is true, correct
and complete to the best of my knowledge. I understand that I could be penalized if I knowingly give false information.
The undersigned hereby consents and authorizes the Department of Human Services and Healthcare and Family
Services to investigate, obtain and verify all information necessary in connection with the request for public assistance.
Such information shall include, but not be limited to, documents of financial institutions, trusts, insurance, stocks/
mutual funds, real estate, pension, SSI/SSA, and any other type of financial resources. Failure to cooperate or provide
documentation or information necessary to determine the applicant's eligibility may result in the denial of assistance.
(Make a mark and have another adult sign next to your mark if you cannot sign your name.)
If you completed this application on behalf of the applicant, sign and complete the following.
Applicant's signature:
Date:
Date:
Signature:
Phone:
Name (print):
Relationship to applicant:
If someone initiates this application on behalf of the applicant, identify the relative, or other person, who can answer
questions about the applicant's financial situation.
Name:
Home Address:
Relationship:
Phone:
Read and Sign
Page 6 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
HFS 2378H (R-02-13)
MEDICARE
Complete for anyone who has Medicare or attach a copy (front and back) of the Medicare card.
Name
Medicare Claim Number
Effective Date
1)
1)
Part
A
Part
B
Part
B
Part
A
2)
2)
HEALTH INSURANCE
Complete for anyone covered by private health insurance or group health insurance, including a plan through their
most recent employer or attach a copy (front and back) of the insurance card.
Name of Covered Person #1:
Policy Holder
Name:
Policy Holder Social Security
Number (Optional):
Insurance Company:
Certificate/Policy
Number:
Medical Claims Mailed To:
Name:
Street:
State:
City:
Zip:
Prescription Claims Mailed To:
Name:
Street:
State:
City:
Zip:
Begin Date:
Dates of Coverage:
End Date:
If insurance is through employer/union, enter employer/union.
Name:
Street:
City:
State:
Zip:
Check all the following benefits provided:
Major Medical
Dental
Vision
LTC
Prescription
Monthly Premium Amount: $
Name of Covered Person #2:
Policy Holder
Name:
Policy Holder Social Security
Number (Optional):
Insurance Company:
Certificate/Policy
Number:
Medical Claims Mailed To:
Name:
Street:
State:
City:
Zip:
Prescription Claims Mailed To:
Name:
Street:
State:
City:
Zip:
Begin Date:
Dates of Coverage:
End Date:
If insurance is through employer/union, enter employer/union.
Name:
Street:
City:
State:
Zip:
Check all the following benefits provided:
Major Medical
Dental
Vision
LTC
Prescription
Monthly Premium Amount: $
FORM A - MEDICARE AND OTHER HEALTH INSURANCE
Page 7 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
HFS 2378H (R-02-13)
Does anyone own a car, truck, motorcycle, boat, trailer or other vehicle?
Complete only for persons who are blind, have a disability or are age 65 or older. If married and living with spouse,
also enter any resources the spouse owns. If yes to any of the following, enter the details below. Attach proof.
Attach additional sheet(s) if needed.
Does anyone own any property(ies) such as a home, vacation home, time share, building or land?
Owner
Address
Type
Value
Amount Owed
1)
1)
1)
$
$
$
$
2)
2)
2)
Owner
Type
Make/Model/Year
Value
Amount Owed
1)
1)
1)
$
$
$
$
2)
2)
2)
Owner
Insurance Company
Policy Number
Face Value
Cash Value
1)
1)
1)
$
$
$
$
2)
2)
2)
Does anyone own any of the following resources? Check all that apply:
Checking Account
Savings
Mutual Funds
Trust Funds
Annuity
Funeral/Burial Plans
Government Bonds
Certificates of Deposit
Burial Plots
Nursing Home Account
Money Market Account
Stocks, Bonds
Mineral/Oil Rights
IRA / 401 K
Other
List, if other:
1)
$
1)
1)
1)
Name of Bank, Company, etc.
Value
Account/Policy #
Type of Resource
Owner(s)
2)
$
2)
2)
2)
3)
$
3)
3)
3)
4)
$
4)
4)
4)
Does anyone own any life insurance?
Yes
No
Yes
No
Yes
No
FORM B - RESOURCE INFORMATION
Page 8 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Business
Promissory Note/Loan
Life Estate
Deferred Comp
Do you have an insurance policy that pays when you are in a nursing home?
Yes
No
If yes, list the following:
Policy Number:
Name of company:
Inheritance
Do you have resources that are held jointly with another person?
Yes
No
(Jointly held resources are those held in two or more names; for example, in your name and in the name of another person(s). This
includes resources that may be held by you and your spouse, son or daughter, brother or sister, grandchild, friend, companion, etc.).
RESOURCE:
VALUE:
NAME AND RELATIONSHIP OF OTHER PERSON(S) HOLDING THE RESOURCE:
Property in Illinois:..............................
$
Property in another state:...................
$
$
$
Certificate of Deposit:.........................
Checking / Savings account:..............
$
$
Other:..................................................
Stocks / Mutual Funds:.......................
Reverse Mortgage
HFS 2378H (R-02-13)
Complete only for persons who live in a nursing home facility or a supportive living facility or who intend to move to a nursing
home facility or a supportive living facility, or who receive or have applied for services through the Department on Aging 's
Community Care Program.
Have you or your spouse within the past 60 months sold or given away any resources; closed any bank
accounts; or made any changes in the way a resource is held (such as, adding a name to a house deed or
creating a trust or annuity)?
Have you or your spouse within the past 60 months: 1) Made any transfers from a revocable trust, or 2)
created an irrevocable trust that does not permit payment to you?
Yes
No
Yes
No
FORM C - TRANSFER OF RESOURCES AND INCOME
Page 9 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Yes
No
1. Have you filed a State or Federal Income Tax Return in the last 5 years?
If YES, which years?
If YES, you are required to provide a copy of each of your tax returns, including all attachments, filed the last 5 years.
Do you or your spouse have an irrevocable trust that has stopped payment within the past 60 months?
2. Has someone else been helping you handle your money and general financial affairs?
No
Yes
This would include helping you handle things such as checking and savings account; handling your life and health insurance
payments; handling financial investments such as IRAs and Certificate of Deposit; handling your income such as Social Security
checks, pension checks or annuity payments. This could be a family member, a friend, or a financial advisor or attorney, or power
of attorney (POA).
If YES, list the name, address, phone number and relationship of each person who assists you with any of these matters:
Name:
Address
City
State
ZIP
Relationship:
Phone:
Is this person your POA?
Yes
No
If YES, for:
Property
Health
Name:
Address
City
State
ZIP
Relationship:
Phone:
Is this person your POA?
No
Yes
If YES, for:
Property
Health
3. Within the last 60 months, did you talk with a financial planner, attorney, family member or anyone
else about your need to reside in a nursing home and discuss any of the following issues?
No
Yes
• How you can use your resources and income to pay for nursing care.
• How you might become eligible for Medicaid if you are unable to pay for the cost of nursing home care from your
own resources.
• Estate Planning - that is, developing a plan to divide any of your resources between your spouse, members of your
family, friends, church or any other organization or placing your resources in a trust for any of these persons.
If YES, who did you talk to? (This may include a financial planner, attorney, banker, family member, friend, community or service
organization, other.)
Name:
Address
City
State
ZIP
Relationship:
Phone:
Name:
Address
City
State
ZIP
Relationship:
Phone:
If yes, enter details below. If you need more space, attach an additional page.
Yes
No
HFS 2378H (R-02-13)
Page 10 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
What other transfers were made?
What was transferred?
Who made the
transfer?
Amount
Received
To Whom?
Date of
Transfer
Market value on the date
of transfer. Attach proof
of how you determined
the market value.
$
Describe the transfer. For example, was it sold, given away, or was there a change in the way it was held?
Why was the transfer made?
Who made the
transfer?
Amount
Received
To Whom?
Date of
Transfer
Market value on the date
of transfer. Attach proof
of how you determined
the market value.
$
Describe the transfer. For example, was it sold, given away, or was there a change in the way it was held?
Why was the transfer made?
FORM C - TRANSFER OF RESOURCES AND INCOME (cont.)
If you need more space, please attach an additional page.
Yes
No
4. In the last 5 years (60 months), did you transfer any of the things you own or any of your income?
Yes
No
5. In the past 60 months, did you take out a reverse mortgage on your home?
If yes, how did you receive the money?
Lump sum payout: $
Line of credit: $
Explain how the money was used:
HFS 2378H (R-02-13)
Page 11 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
If yes, enter case number:
Complete only for persons who are married and live in a nursing home facility or a supportive living facility or who
intend to move to a nursing home facility or a supportive living facility, or who receive or have applied for services
through the Department on Aging's Community Care Program.
Do you want to transfer resources to your spouse?
If yes, attach copies of your spouse's resources.
Do you want to give income to your spouse?
If yes, attach copies of your spouse's income.
Does your spouse live in a nursing home facility or a supportive living facility?
Does your spouse receive or has your spouse applied for services through the
Department on Aging's Community Care Program?
Does your spouse receive medical benefits through the Department of Human
Services or the Department of Healthcare and Family Services?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
FORM D - TRANSFER OF RESOURCES OR INCOME TO SPOUSE
HFS 2378H (R-02-13)
Page 12 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Federal, State and City taxes withheld: $
Complete only for employed persons who are blind, have a disability or are age 65 or older. Also enter the
employment expenses for an employed spouse or parent of a child under age 18 if they live together.
Employed person's name: (1)
How often paid:
Social Security tax withheld: $
Does the person buy or bring lunch to work?
Does the person buy uniforms or special tools?
If yes, enter the items bought,
how often, and cost. Attach proof.
How does the person get to and from work?
Please list,
if other:
If person uses own car, how many miles to and from work?
If other, enter type and cost. Attach proof.
Monthly amount: $
Must the person pay union dues, group life insurance
premiums, group health insurance premiums, or retirement
plan withholding as a condition of employment?
Amount received before deductions (gross amount): $
Federal, State and City taxes withheld: $
How often paid:
Social Security tax withheld: $
Does the person buy or bring lunch to work?
Does the person buy uniforms or special tools?
If yes, enter the items bought,
how often, and cost. Attach proof.
How does the person get to and from work?
Please list,
if other:
If person uses own car, how many miles to and from work?
If a person takes the bus, what is the fare to and from work? $
If other, enter type and cost. Attach proof.
Monthly amount: $
Must the person pay union dues, group life insurance
premiums, group health insurance premiums, or retirement
plan withholding as a condition of employment?
Employed person's name: (2)
Amount received before deductions (gross amount): $
If a person takes the bus, what is the fare to and from work? $
Weekly
Every Two Weeks
Bi-Monthly
Monthly
Buy Lunch
Bring Lunch
Yes
No
Own Car
Bus
Other
Every Two Weeks
Weekly
Bi-Monthly
Monthly
Yes
No
Bring Lunch
Buy Lunch
No
Yes
Other
Own Car
Bus
No
Yes
FORM E - EMPLOYMENT EXPENSES
HFS 2378H (R-02-13)
Page 13 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Source of Income:
Enter the following information for each absent spouse.
Absent Spouse's Name
Spouse of Whom?
(1)
Street
Apt. No.
City
State
Zip
County
Social Security Number:
Monthly Gross Income: $
Absent Spouse's Name
Spouse of Whom?
(2)
Street
Apt. No.
City
State
Zip
County
Social Security Number:
Monthly Gross Income: $
(If employed, include employer's name and address below.)
Name:
(If employed, include employer's name and address below.)
Name:
Address:
Address:
Source of Income:
FORM F - ABSENT SPOUSE INFORMATION
HFS 2378H (R-02-13)
Page 14 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
Name of person who is requesting
a disability determination:
EDUCATION
Highest Grade Completed
At What Age?
Date
Technical or Vocational Training?
Special Education Classes While in School?
If yes, please list:
Is the person able to read and write English?
Is the person able to speak English?
If no, what language is spoken?
WORK HISTORY
Has the person ever worked?
Give History of last 3 jobs.
Job
Title (1):
Duties (1):
To:
From:
Employment Dates
Full or
Part Time
Reason for Leaving
Job
Title (2):
Duties (2):
To:
From:
Job
Title (3):
Duties (3):
To:
From:
If no, how does the person support his or her self?
Yes
No
Technical
Vocational
Yes
No
Yes
No
Yes
No
Full Time
Part Time
Part Time
Full Time
Part Time
Full Time
FORM G
Complete this form only for persons who believe they have a disability, but the Social
Security Administration has not made the disability determination.
Eligibility Worker:
Form G is a required
part of the 183 packet
that goes to CAU, unless
a completed 183 B is sent.
HFS 2378H (R-02-13)
Page 15 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
MEDICAL PROVIDERS TREATING THIS PERSON
Doctor's Address
Doctor's Phone Number
Name of Doctor
Has this person received treatment for this medical problem in
the last three months?
Yes
No
Has this person been hospitalized or used community health
services for this problem in the last 12 months?
Yes
No
If yes, where?
FORM G (cont.)
HFS 2378H (R-02-13)
Page 16 of 17
For more information, call 1-800-843-6154 (TTY: 1-800-447-6404). The call is free.
To ask for rebates, you must send this form with the rest of your application.
Part A
The main person whose name is on the insurance must sign this part of the form. Often this person is called the
policyholder. This person may get the health insurance from a job.
Policyholder's Name
(list last name, then first name):
Home Address:
Apt. #:
State:
City:
Zip:
Social Security
Number (Required):
Phone Number:
We must have the Social Security Number (SSN) so we may pay the rebate to this person.
Group Number:
Policy Number:
Tell us the names of the family members you want rebates for:
I agree to call All Kids/FamilyCare right away if this health insurance ends, someone is added or taken off the health
insurance, the amount paid for the insurance changes, covered benefits change or someone else becomes the
policyholder.
I authorize my employer, plan administrator and insurance company to provide the information requested in Part B on
the next page for the purpose of determining whether I qualify for All Kids/FamilyCare. I also authorize my employer,
plan administrator and insurance company to verify my coverage and any of the information below for any time when
I get All Kids/FamilyCare Rebate.
Signature of Employee/Policyholder:
Need help? Visit www.allkids.com or call 1-866-All-Kids (1-866-255-5437). If you use a TTY, call 1-877-204-1012. The call is free.
FORM H
Rebate Form for All Kids and FamilyCare
Use this form if you want All Kids or FamilyCare Rebate.
A rebate is a monthly amount we will pay you if you already pay for health
insurance for yourself, your spouse or your children. If you choose to get
rebates, you will use your current insurance card to get health care.
Only families who have health insurance can get rebate payments. Also, only families with a certain amount of income
can get rebates. You may be able to get rebates if your family is like one in the list below:
You are the only person in your family
You may qualify for rebates if the income you get each month is
between $1,274 and $1,915.
You have two people in your family
You may qualify for rebates if the income you get each month is
between $1,720 and $2,585.
You have three people in your family
You may qualify for rebates if the income you get each month is
between $2,166 and $3,255.
You have four people in your family
You may qualify for rebates if the income you get each month is
between $2,611 and $3,925.
HFS 2378H (R-02-13)
FORM H (cont.)
Part B
This part of the form must be completed by 1) the employer providing the health insurance, or 2) the insurance agent.
Note to Employer/Insurance Agent: The employee/policyholder named on the front of this form is applying for
help to cover the cost of their family's health insurance premiums. Please assist them by completing the
information below and returning the form to the employee/policyholder as soon as possible. (As used below
"employee" applies to an employee or private policyholder.) For help in completing this form, call
1-877-805-5312. The call is free.
Employer (if employer policy):
Employer address:
City:
State:
Zip:
Person completing this form:
Fax:
Phone:
Policy
Number:
Insurance
Company:
Group
Number:
What benefits are covered?
Check all that apply.
Physician Services
Hospital Inpatient Services
Amount of premium (for physician and hospital inpatient) paid by employee: $
Include amounts paid for dental, vision and prescription coverage.
Premiums are paid:
Weekly
Every 2 weeks
Twice a month
Monthly
Every 2 months
Quarterly
Semi-annually
Annually
List the persons covered by the employee premium contribution:
Does the employer pay 100% of the cost of the employee's coverage?
If no, how much of the amount listed above is for physician and hospital inpatient coverage of the employee only
(single rate)?
$
Include single rate amounts for dental, vision and prescription coverage.
Enrollment period for policy:
Date the premium listed above began or begins:
Date of next scheduled change in premium:
Authorized signature
of employer/agent
Date:
Return this completed form to the employee for submission with the application.
Need help? Visit www.allkids.com or call 1-866-All-Kids (1-866-255-5437).
If you use a TTY, call 1-877-204-1012. The call is free.
Yes
No
Page 17 of 17
IOCI13-543
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Completed 10 September 2021

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