Add or replace text, adjust formatting, insert legally binding eSignatures, and send documents for signing without hopping between apps.
IL DHFS HFS 3654 2012-2025 free printable template
Show details
Address Zip 3. How have you paid your nursing care before filing this application for medical assistance Next Page HFS 3654 R-3-12 Last Page Page of 4. 6. What is your marital status Single Married Divorced Widow / Widower Legally Separated List the name address phone number and Social Security Number SSN of your current or most recent spouse SSN Optional If your spouse is deceased list the following Date of Death Place of Death City If you are divorced please include a copy of the divorce...decree with this form 3654 when subitted. If this is not available list the following Date of Divorce Place of Divorce City First Page Previous Page 7. State of Illinois Department of Healthcare and Family Services ADDITIONAL FINANCIAL INFORMATION FOR LONG TERM CARE APPLICANTS HFS USE ONLY INSTRUCTIONS Read carefully and follow all instructions. DHS CASE No* Answer ALL questions completely and accurately. PLEASE PRINT Sign the document. Name of LongTerm Care facility if applicable OIG USE ONLY...If submitted by hospital/LTC facility provide the date of admission and actual or expected date of discharge OIG CASE No* Submitting hospital/LTC facility name DR DC APPLICANT Last Name Middle Initial First Name Street State City County Zip Code Phone Number MAILING ADDRESS If different from above 1. Have you filed a State or Federal income tax return in the last 60 months Yes No 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 three years. 2. 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. Has someone else been helping you handle your money and general financial affairs 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 IRA s and Certificate s 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 Relationship Phone Is this person your POA If YES for Property Health 5. 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 How you can use your income and resources to pay for nursing care. How you might become eligible for medical assistance if you are unable to pay for the cost of nursing home care. 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.
pdfFiller is not affiliated with any government organization
Fill out, sign, and share forms from a single PDF platform
Manage all your documents quickly and securely in the cloud.
Edit and sign in one place
Create professional forms
Add and customize fillable fields to tailor each form to your needs and ensure easy completion without printing and scanning.
Simplify data collection
Quickly share forms via email or a secure link, enabling anyone to complete forms online in seconds, on any device.
Manage forms centrally
Keep all your forms and templates organized in one secure, cloud-based platform, track changes easily, and export documents in any format.
Why pdfFiller is the best tool for your documents and forms
End-to-end document management
From editing and signing to collaboration and tracking, pdfFiller has everything you need to get your documents done quickly and efficiently.
Accessible from anywhere
pdfFiller is fully cloud-based. This means you can edit, sign, and share documents from anywhere using your computer, smartphone, or tablet.
Secure and compliant
pdfFiller lets you securely manage documents following global laws like ESIGN, CCPA, and GDPR. It's also HIPAA and SOC 2 compliant.
Understanding the DHFS HFS 3654 Form
What is the DHFS HFS 3654 Form?
The IL DHFS HFS 3654 form is a document required by the State of Illinois for individuals applying for medical assistance, specifically in relation to long-term care. This form collects essential financial and personal information to assess the applicant's eligibility for benefits. It is a critical step in the application process for individuals seeking support within healthcare and family services.
Who Needs the DHFS HFS 3654 Form?
Individuals applying for long-term care assistance in Illinois are required to complete the HFS 3654 form. This includes seniors, individuals with disabilities, and other residents who need financial support for healthcare. If you or a family member plan to apply for benefits related to nursing home care or similar services, this form is essential.
When to Use the DHFS HFS 3654 Form?
The HFS 3654 form should be used during the initial application for medical assistance before or when entering a long-term care facility. It is necessary to submit this form along with any other required documents to ensure the application is processed efficiently. Timing is vital, especially if you are nearing a date for admission to a care facility.
Required Documents and Information
When filling out the HFS 3654 form, several pieces of information and documents are required. This includes identification details, income statements, asset documentation, and information regarding any prior residences. It may also be necessary to provide past tax returns to support financial data. Ensuring that you have all relevant information can significantly simplify the completion process and avoid delays.
Best Practices for Accurate Completion
Accurate completion of the IL DHFS HFS 3654 form is critical for a successful application. It is advisable to carefully read each section and answer all questions truthfully and completely. If guidance is needed, consider seeking assistance from a family member or a professional who is familiar with the form. Double-checking entries and ensuring that all required documents are submitted with the form can help prevent common errors that may lead to delays.
Common Errors and Troubleshooting
When filling out the HFS 3654 form, several common errors can occur, such as missing signatures, incorrect or incomplete financial data, and failure to provide required documentation. To troubleshoot these issues, review the completed form against the guidelines provided in the instructions carefully. If any discrepancies are found, correcting them promptly can enhance the chances of a smooth application process.
Frequently Asked Questions about illinois hfs 3654 pdf form
What is the purpose of the IL DHFS HFS 3654 form?
The purpose of the IL DHFS HFS 3654 form is to gather necessary information for assessing eligibility for medical assistance concerning long-term care in Illinois.
Who should complete the HFS 3654 form?
The HFS 3654 form should be completed by individuals applying for long-term care assistance in Illinois, such as seniors or individuals with disabilities.
pdfFiller scores top ratings on review platforms
Easy, efficient, organized. Not clear when trying to erase, edit, change.
fast to do i love it make it easier than before
People Also Ask about illinois hfs 3654 printable
How do I check my Medicaid status in Illinois?
If you aren't sure if your Medicaid coverage has been approved yet or if it is still active, you can check Manage My Case or call the state's Automated Voice Recognition System (AVRS) at 1-855-828-4995 with your Recipient Identification Number (RIN).
What is state of Illinois Healthcare and Family Services Medical Card?
The Healthcare and Family Services (HFS) Medical Benefits program – Illinois Medicaid – is a comprehensive healthcare program for qualifying low income individuals age 65 and above or younger individuals with a disability within the state of Illinois.
What is the Illinois Medicaid number for providers?
Provider Help Line: 1-800-804-3833 · 1-877-434-1082 TTY.
Can I print my Medicaid card online Illinois?
To print your card or provisional letter, sign into the system using your username and password. Select your application from the Tracking Inbox. If you are wanting to print your provisional letter, click Provisional Letter. If you are wanting to print your card, click Print Card.
How do I look up my Illinois medical card?
The HFS Medical Card contains a toll-free number (1-855-828-4995) for customers to call to verify their own, or a family member's, eligibility. The number connects to an Automated Voice Response System.
How do I check the status of my Medicaid in Illinois?
1-800-842-1461. To use the automated system, you must have the individual's Medicaid Recipient Identification Number (RIN) and the date of service for which you need eligibility information.
Related pages
Related Content hfs form financial
Related to hfs form financial
Related Catalogs
If you believe that this page should be taken down, please follow our DMCA take down process
here
.
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.