Illinois Medicaid Redetermination Medical Renewal Form Page 2
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5State of Illinois
Department of Healthcare and Family Services
Department of Human Services
991010101
Illinois Medicaid Redetermination
Case ID: 066066010011Y
Medical Renewal Form
1. Do these people still live with you?
£
£
MEMBER NAME1
01/01/1999
Yes
No
2. Tell us about anyone else who lives with you:
Relationship to you
Name
Date of birth
(for example: spouse, child,
First, Middle, Last, Suffix (Jr., Sr., II or III)
)
(month/day/year
parent)
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
£
£
3.
Did you or anyone living with you get new health insurance in the last year?
Yes
No
If yes, name of insurance plan:_________________________________ Policy number: _____________________________
Who is covered by this health insurance? ____________________________________________________________________
Name of insurance plan:_______________________________________ Policy number: _____________________________
Who is covered by this health insurance? ____________________________________________________________________
Page 1
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E-mail us at or send a fax to 1-866-661-7025.
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Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
02-03-7
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