Application Form For Illinois Cares Rx - Illinois Department On Aging 2010 Page 3
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1
2
3(STEP 4 continued…)
19
Illinois Cares Rx Benefits. Your QAR can choose help paying for prescriptions.
F
F
a Does your QAR have Medicare? yes
no
(If “no,” go to Line 20.)
F
F
b Does your QAR have HIV/AIDS? yes
no
(See instructions for additional benefits.)
20
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
F
F
with Illinois Cares Rx? yes
no
f “no,” go to Step 5.)
(I
F
F
b Does your QAR want a $25 monthly rebate instead of help paying for prescriptions? yes
no
Do not mark “yes” if your QAR is 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.
5
STEP
:
Sign
below.
(Attach proof of authority if someone else signs for you or your spouse.)
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.
21
22
_______________________________
___/
___/___
___________________________
___/___/___
Signature of person named on Line 2
Date
Signature of person named on Line 9
Date
23
_______________________________
___/
___/___
Signature of person named on Line 16
Date
(If younger than 18, see instructions.)
6
Send us the completed application form.
STEP
:
Mail this application to:
ILLINOIS DEPARTMENT ON AGING
PO BOX 19021
SPRINGFIELD IL 62794-9021
Print 2 or more copies. Then read Step 5 and sign your names. Mail 1 copy (Step 6). Keep the rest for your files.
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