HFS 3731 (R-9-09)
State of Illinois
Department of Healthcare and Family Services
SUPPORTIVE LIVING PROGRAM
NOTICE OF INVOLUNTARY DISCHARGE
Due to the following reason(s), you will be discharged from
on
REASON:
You have a right to appeal the supportive living facility's (SLF) decision to discharge
you. You may file a request for a hearing with the Department within ten days after
receiving this notice. If you request a hearing, you will not be discharged during that
time unless you are unsafe to yourself or others and the SLF has given you a notice for
an emergency discharge. If the SLF has not given you a notice for an emergency
discharge, and if the decision following the hearing is not in your favor, you will not be
discharged prior to the tenth day after receipt of the Department's hearing decision
unless you are unsafe to yourself or others. If the SLF provided you with a notice of
emergency discharge, and the decision following the hearing is in your favor, you will
be entitled to readmission to the SLF upon the first available apartment. A form to
appeal the SLF's decision and to request a hearing is attached. If you have any
questions, call the Department of Healthcare and Family Services at 217/782-0545.
Name, Address and Telephone Number of Person Charged With the Responsibility of
Supervising the Discharge:
Resident Name:
Resident Identification Number:
Date of Birth:
Name of Facility Date
(SIGNATURE OF SLF MANAGER)
(DATE)
