Form Adad-16 - Application For Illinois Cares Rx - Illinois Department On Aging Page 3
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3Step 4: Sign below.
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 and the Social Security Administration 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 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 (3) citizenship and identification information maintained by the
Illinois Secretary of State, 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.
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___________________________ / _____ / ______
___________________________ / _____ / ______
Claimant’s signature
Date
Spouse’s signature
Date
Step 5: Send us the completed application form.
Mail this application to:
ILLINOIS DEPARTMENT ON AGING
PO BOX 19021
SPRINGFIELD IL 62794-9021
Instructions
Line 5b and 11b (for Illinois Cares Rx)
If you are not a U.S. citizen or qualified noncitizen, you may qualify for Illinois Cares Rx Basic, not Illinois Cares Rx
Plus. You may skip Line 5b (Line 11b for your spouse).
Information for citizens:
If you are a U.S. citizen age 64 or older who is not currently and will not be eligible for Medicare,
federal law now requires that you submit proof of citizenship and/or identification to receive help paying for
prescription drugs.
Option 1 – Proof of Citizenship
Option 2 – Proof of Citizenship and
Proof of Identification
Submit one of the following documents:
Submit one of the following documents from each category:
U.S. Passport
Birthplace Documents
Certificate of Citizenship
(N-550 or N-561)
Certified copy of a birth certificate from the state or county
where the person was born
Certificate of Naturalization
(N-550 or N-570)
Final adoption decree
Official military record that shows place of birth
Federal law prohibits us from
Papers showing a person was employed by the federal
accepting photocopies.
You must submit
government before 1976
original documents or certified copies.
Identity Documents
Please put your name and Social Security
number on each document. Certified copies
Driver’s license
will not be returned to you. Original
Government-issued ID card (city, county, or state)
documents will be returned to you at the
address listed on Line 3.
School-issued ID card
If you move, remember to notify us by
U.S. military dependent card
calling the Circuit Breaker Division at
U.S. military ID card
1-800-624-2459
1-800-544-5304 (TTY)
or
.
(R-3/07) ADAD-16,
Page 3
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