Form Il-1363 - Schedule A - Physician'S Statement - 2009

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State of Illinois
Illinois Department on Aging
2009 Schedule A
Physician’s Statement
Attach to the claimaint’s Form IL-1363.
You may need to complete Schedule A if you were younger than 65 years of age on January 1, 2010, and
• you are the claimant, or
• you are the claimant’s spouse who is applying for help paying for prescription drugs or the monthly rebate.
Step 1: Answer the following questions to determine if you should complete this
schedule.
1
Did you receive Social Security disability benefits in 2009? .................................................... yes
no
2
Did you receive disability benefits from Railroad Retirement or Civil Service in 2009? ........... yes
no
3
Did you receive disability benefits from the Veterans Administration in 2009? ........................ yes
no
4
Did you have a Class 2 disability card from the Illinois Secretary of State’s office in 2009? ... yes
no
If you answered “yes” to any of the questions 1 through 4, stop. Do not complete this schedule,
instead see the instructions for what you may need to attach to Form IL-1363.
Step 2: Complete the following information about yourself.
Please print.
Complete a separate Schedule A for each person and attach it to the claimant’s Form IL-1363.
5
9
Social Security number
Birth date
Month
Day
Year
6
10
Name
_________________________________________
Phone
( __ __ __ ) __ __ __ - __ __ __ __
First
MI Last
Area Code
7
11
Address
_____________________________
Apt.
______
Claimant’s Social Security number
(from Line 1 on Form IL-1363)
8
City
___________________
State
____
ZIP
__________
Step 3: A physician must complete the following information about the person named on
Line 6.
The patient must meet the total disability criteria established by the Social Security Administration. Social Security
Administration guidelines do not include alcoholism or drug abuse as a qualification for disability status.
12
Patient’s name
_________________________________________________________________________
First
MI
Last
13
Date patient became disabled
___ ___ / ___ ___ / ___ ___ ___ ___
Month
Day
Year
14
Was the patient able to work for a living after the above date? ................................................. yes
no
15
Has the disability lasted or is it expected to continue for 12 months or more? ......................... yes
no
16
What is the nature of the disability?
_________________________________________________________
17
Physician’s name
_______________________________________________________________________
18
Physician’s signature and date
________________________________________ __ __/__ __/__ __ __ __
Month
Day
Year
19
Physician’s Illinois registration number 3 6 -
____ ____ ____ ____ ____ ____
(This number is issued by the Illinois Department of Financial and Professional Regulation.)
20
Physician’s phone
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Area Code
Schedule A (IL-1363)
This form is authorized as outlined by the Senior Citizens and Disabled Persons Property Tax Relief and Pharmaceutical Assistance Act.
1 of 1 (R-12/09)
Disclosure of this information is REQUIRED. Failure to provide information could delay your grant and/or prescription coverage.
IL-402-1094

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