Illinois Medicaid Redetermination Medical Renewal Form
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5State of Illinois
Department of Healthcare and Family Services
Department of Human Services
Illinois Medicaid Redetermination
00067
HH_NAME (NMG_NULL_ENGLISH)
ADDRESS LINE1
991010101
IMR7AZE
ADDRESS LINE2
00-IMR2BR1E-3
NMG - EN
CITY ST
February 12, 2014
Case ID: 066066010011Y
Dear HH_NAME (NMG_NULL_ENGLISH),
It is time to renew your medical coverage!
It’s time for renewal, also known as “redetermination” or “re-de.”
Here’s what to do:
1. Answer all questions on this form.
2. Make sure all the information is correct. If any information is wrong, cross it out and
write in the correct information.
3. Sign this form at the bottom of page 4.
4. Attach proof documents for income and expenses and other proofs we ask for.
5. Send your signed form and all proofs by February 25, 2014.
Send your form and proofs to us one of these ways:
® Fax your form and proofs to 1-866-661-7025
® Mail your form and proofs in the envelope that we sent you
® E-mail your form and proofs to
Your medical benefits may end if you do not send your proofs by February 25, 2014.
Call us at 1-855-458-4945 (TTY: 1-855-694-5458) if you cannot send everything on time
or if you have questions. We may be able to help you get the proofs you need.
Thank you,
Illinois Medicaid Redetermination
Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!
Monday to Friday from 7 a.m. to 7:30 p.m. and Saturday from 8 a.m. to 1 p.m.
E-mail us at or send a fax to 1-866-661-7025.
Tenemos información en español. ¡Servicio de intérpretes gratis!
Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
01-03-7-01
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