Application Form For Illinois Cares Rx - Illinois Department On Aging 2010
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3Use your 'Mouse' or the 'Tab' key to move through the fields, use your 'Mouse' or 'Space Bar' to enable the "Check Boxes".
Clerk ID
State of Illinois
Illinois Department on Aging
Application for Illinois Cares Rx
After Form IL-1363 has been filed in a claim year
Official use only
Complete this application only if you want help paying for drugs or a monthly rebate and did not make this
request on your previously filed 2010 Form IL-1363, Application for Circuit Breaker and Illinois Cares Rx.
1
STEP
:
Claimant Information.
1
Social Security number
2
Name
_________________________________________________________________________________
First
M I
Last
3
Address
_______________________________________________________________
Apt.
__________
City
________________________________________________
State
_______
ZIP
________________
4
Are you
Male
Female
F or your Illinois Cares Rx Benefits or Monthly Rebate.
5
Are you a
U.S. citizen or
qualified noncitizen? (See instructions.)
You may still qualify for Illinois Cares Basic even if no box is checked above.
6
Illinois Cares Rx Benefits. You can choose help paying for prescriptions.
F
F
a Do you have Medicare? yes
no
(If “no,” go to Line 7.)
F
F
b Do you have HIV/AIDS? yes
no
(See instructions for additional benefits.)
7
Monthly Rebate. You can choose to receive a $25 monthly rebate instead of help paying for prescriptions.
a Do you have private insurance that pays for your prescription drugs; or do you have Veterans Administration
(VA) benefits; or are you enrolled in a Medicare Part D plan that does not coordinate with Illinois Cares Rx?
F
F
yes
no
f “no,” go to Step 2.)
(I
F
F
b Do you want a $25 monthly rebate instead of help paying for prescriptions? yes
no
Do not mark “yes” if you are receiving prescriptions through a coordinating Illinois Cares Rx Medicare
Part D plan. If you are enrolled in one of these plans, Illinois Cares Rx will help pay for your prescriptions.
2
For your Spouse’s Illinois Cares Rx Benefits or Monthly Rebate.
STEP
:
8
Spouse’s Social Security number
9
Spouse’s Name
_________________________________________________________________________
First
M I
Last
10
Spouse’s birth date
Month
Day
Year
(Continued on next page.)
ADAD-16 (R - 12/10)
1 of 5
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.
IOCI 0214-11
Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage.
IL-402-2019
Go to Page 2
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