Form Il-1363 - Application For Circuit Breaker

Step 9: Complete the following information if you or your spouse want to

receive information about the

Illinois Rx Buying Club or the

program.

Do you or your spouse want to get information about the

Illinois Rx Buying Club?

yes

Do you or your spouse want to get information about the

program?

yes

Step 10: 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

permission to get records from anyone concerning information on this form. I authorize the Illinois Department of Revenue to disclose information from any of

my tax returns for the limited purpose of confirming my eligibility for benefits. As permitted by law, and subject to resource availability, I 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.

_________________________________/___/___

___________________________(____)________

Claimant’s signature

Date

Preparer’s name (Please print or type.)

Phone number

_________________________________/___/___

Spouse’s signature (If living together)

Date

If you need additional assistance

• visit the Web site at

TTY)

• to find a local agency serving seniors, call the

• call us at 1-800-624-2459 or

Senior HelpLine at 1-800-252-8966 (Voice and

1-800-544-5304 (TTY)

If applying for ALL benefits - including

If ONLY applying for a grant or license plate discount

Illinois Cares Rx

CIRCUIT BREAKER & DRUG COVERAGE

CIRCUIT BREAKER

ILLINOIS DEPARTMENT ON AGING

PO BOX 19022

PO BOX 19003

SPRINGFIELD IL 62794-9022

SPRINGFIELD IL 62794-9003

Postmark deadline for filing is December 31, 2006.

This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act. Disclosure of this information is

IL-1363 4 of 4 (R-12/05)

REQUIRED. Failure to provide information could delay your grant and prescription coverage. This form has been approved by the Forms Management Center.

IL-402-1093

Form Il-1363 - Application For Circuit Breaker - 2005 Page 4

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