2010 Schedule B - Qualified Additional Resident (Qar) Form - Illinois Department On Aging

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State of Illinois, Department on Aging

2010 Schedule B

Qualified Additional Resident (QAR)

Attach to claimant’s Form IL 1363. (A separate Schedule B must be completed for each QAR.)

Who is a qualified additional resident?

A qualified additional resident is an individual, other than your spouse,

• who lived with you in the same residence in 2010 and in 2011 at the time you file your 2010 Form IL-1363; and

• for whom you, or you and your spouse, provided more than half of that person’s total financial support in 2010; and

• who is not filing a separate 2010 Form IL-1363.

STEP

Tell us about your qualified additional resident.

Please print.

Social Security number

Name

________________________________________________________________________________

First

Last



Birth date

Check if requesting Illinois Cares Rx drug coverage.

Month

Day

Year

Attach proof of age (first-time filer). If the person listed in Line 2 is younger than 65 years of age

and the box in Line 4 is checked, attach proof of disability.

For your QAR’s Illinois Cares Rx benefits or monthly rebate.

(See instructions)



Is your QAR a

U.S. citizen or

qualified noncitizen?

Your QAR can either get help paying for prescriptions or instead your QAR can get a $25 monthly rebate.

Illinois Cares Rx Benefits. Your QAR can choose help paying for prescriptions.

a Does your QAR have Medicare?

yes

b Does your QAR have HIV/AIDS? yes

Monthly Rebate. Your QAR can choose to receive a $25 monthly rebate instead of help paying for prescriptions.

a Does your QAR have private insurance that pays for prescription drugs; or does your QAR have Veterans

Administration (VA) benefits; or is your QAR enrolled in a Medicare Part D plan that does not coordinate

with Illinois Cares Rx? yes

b Does your QAR want a $25 monthly rebate instead of help paying for prescriptions? yes

Do not mark “yes” if receiving prescriptions through a coordinating Illinois Cares Rx Medicare Part D

plan. If your QAR is enrolled in one of these plans, Illinois Cares Rx will help pay for their prescriptions.

STEP

Claimant sign below.

Under penalties of perjury, I certify that the individual listed in Step 1 is a qualified additional resident for whom I, or my spouse and I, provided more than half

of their total financial support in 2010, and that this individual lived with me in the same residence in 2010 and in 2011 at the time I filed my 2010 Form IL-1363.

_______________________________________ ___/___/___

Claimant’s signature

Date

Claimant’s Social Security number

STEP

QAR sign below.

(Attach proof of authority if someone else signs for you.)

Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete. I give the state of Illinois permission

to get records from anyone concerning information on this form. As permitted by law, and subject to revocation, I authorize disclosure of the following information to,

by, and between the Illinois Department on Aging and the Illinois Department of Healthcare and Family Services for the Circuit Breaker/Illinois Cares Rx Programs:

(1) citizenship, identification, and HIV/AIDS status information maintained by the Illinois Department of Public Health; (2) tax return information maintained by the

Illinois Department of Revenue and the Internal Revenue Service (3) citizenship and identification information maintained by the Illinois Secretary of State and the

United States Citizenship and Immigration Services (USCIS); and (4) identification information for ride programs offered by mass transit authorities, for the limited

purposes of confirming my eligibility for applicable benefits and related outreach enrollment efforts through the end of the appropriate audit period. If resource

availability permits, I also authorize the state of Illinois to apply on my behalf for any federal drug benefits I may be eligible to receive under the Medicare program.

I assign to the state of Illinois my right to any benefits, including reimbursement, under any private plan of assistance, public assistance program, insurance plan,

or from any liable third party, for prescription drugs that I receive through the Illinois Cares Rx program. I also agree that if I receive any such payments or other

payments or benefits under the programs on this form in error, or that I was not entitled to, I will repay them to the state of Illinois. I authorize release of medical and

pharmaceutical records for audit and verification purposes, and exchange of health care information between any drug utilization review service authorized by the

state of Illinois and any of my physicians and pharmacists to the extent necessary for the operation of a drug utilization review service.

_____________________________ ___/___/___

Signature of person named on Line 2 (QAR)

Date

Signature of Authorized Representative for the QAR

Date

(If younger than 18, see instructions.)

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