Illinois Medicaid Redetermination Medical Renewal Form (Page 5 of 5) in pdf

Illinois Medicaid Redetermination Medical Renewal Form Page 5

9. Read and sign below:

I understand that officials in charge of my health benefits may check all information on this form.

I understand they may check my information electronically. If they ask for my help checking

information, I must cooperate.

I understand that anyone who knowingly lies or provides untrue information, or arranges

for someone to knowingly lie or provide untrue information, or intentionally misuses the

health benefits card issued by the State of Illinois, may be committing a crime which can be

prosecuted or punished under federal law, state law, or both.

If the Illinois Department of Healthcare and Family Services pays medical bills for me, the State

of Illinois may collect my medical support payments instead of me.

I am signing this form under the penalty of perjury. That means the information I have provided

on this renewal form is true to the best of my knowledge, and I may be punished under law if I

provide false or untrue information.

________________________________________________

______________________________

Your signature

Today's date

10. Remember! Make sure you answered all questions and signed the form.

Send this form to us with all proofs by February 25, 2014.

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Illinois Medicaid Redetermination Medical Renewal Form Page 5