IL DHFS HFS 3654 2012-2025 free printable template
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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...
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How to fill out illinois hfs 3654 pdf form
How to fill out IL DHFS HFS 3654
01
Obtain the IL DHFS HFS 3654 form from the official website or relevant agency.
02
Read the instructions provided at the top of the form carefully.
03
Fill in your personal information in the designated sections including name, address, and contact details.
04
Provide any required identification numbers, such as Social Security Number or case number.
05
Complete the sections that pertain to your specific situation and needs.
06
Review all the information you have entered for accuracy.
07
Sign and date the form where indicated.
08
Submit the completed form to the appropriate agency or office specified in the instructions.
Who needs IL DHFS HFS 3654?
01
Individuals or families applying for state assistance programs.
02
Persons seeking healthcare coverage or benefits under state programs.
03
Providers or organizations assisting clients with applications for benefits.
04
Anyone required to report changes in their income or circumstances to continue receiving assistance.
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People Also Ask about 3654 state illinois
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.
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What is IL DHFS HFS 3654?
IL DHFS HFS 3654 is a form used in Illinois for reporting health-related information and compliance with state health regulations.
Who is required to file IL DHFS HFS 3654?
Entities such as healthcare providers, organizations, and facilities that fall under the jurisdiction of the Illinois Department of Healthcare and Family Services are required to file IL DHFS HFS 3654.
How to fill out IL DHFS HFS 3654?
To fill out IL DHFS HFS 3654, provide accurate information regarding the health services provided, including usage statistics, patient demographics, and compliance details as per the guidelines outlined in the form instructions.
What is the purpose of IL DHFS HFS 3654?
The purpose of IL DHFS HFS 3654 is to collect data that helps monitor the quality of health services provided in Illinois and ensures compliance with state regulations.
What information must be reported on IL DHFS HFS 3654?
IL DHFS HFS 3654 requires reporting information such as service types offered, number of patients served, financial data, staffing details, and compliance with health regulations.
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