PDF
Word
Sample Illinois Medicaid Redetermination - Illinois
What Is an Illinois Medicaid Redetermination Form?
An Illinois Medicaid Redetermination is a form that should be completed by applicants every year to renew their Medicaid coverage. By filling in this form annually, applicants provide actual information about their income, which can change from year to year. The completed form and the proof documents for income have to be sent by mail or email provided in the form. The response period is 10 business days, but for Illinois Medicaid Redetermination status checks, the customer can call the Illinois Medicaid Redetermination Hotline.
This form was released by the Illinois Department of Healthcare and Family Services and the latest version of the form was issued in on . A sample Illinois Medicaid Redetermination is available for download below.
Illinois Medicaid Redetermination Instructions
The instructions for filling in Illinois Medicaid Redetermination Form are as follows:
- Provide actual information about people who live with you, including people not specified before and pregnant (Sections 1 through 3).
- Provide information if you or anyone living with you has got new health insurance in the last year.
- Notify if you or anyone who lives with is going to file а federal income tax return next year.
- If you are dependent on anyone's tax return, indicate this person and relationship to you.
- Provide information about your income and income of everyone living with you from sources listed below. Confirm the total amount per month regarding every specified source. If you don't confirm some indicated amount, enter the correct amount in Section 8.
- Notify if you or anyone living with you рау expenses listed below.
- A proof of the amount for income received and proof of аll expenses paid in the last 30 days should be attached to the form.
- Signature and date of the filer.
Download Sample Illinois Medicaid Redetermination - Illinois
1
2
3
4
