Schedule A - Doctor'S Statement - 1999

Illinois Department of Revenue

1999 Schedule A

Doctor’s Statement

Attach to your Form IL-1363.

Read this information first

Use this schedule when you, the claimant, wish to apply for Circuit Breaker or Pharmaceutical Assistance

as a disabled person or when your husband or wife wishes to apply for Pharmaceutical Assistance as a

disabled person. Attach this completed schedule to Form IL-1363, Circuit Breaker and Pharmaceutical

Assistance Claim.

If you are 65 years of age before January 1, 2000, do not use this schedule. Instead, you should apply for

the program under the age (rather than the disability) requirement.

Step 1: Tell us about the claimant.

Please print.

1

Social Security number

4 Birth date __ __/__ __/__ __ __ __

Month

Day

Year

-

2

Name______________________________________________

5 Phone

(____) ___________

Last

First

MI

Area code

3

Address_________________________________ Apt._______

City_______________________ State____ ZIP____________

Step 2: Ask your doctor to complete the following information.

Please print.

Note: The patient must meet the total disability criteria established by the Social Security Administration.

Beginning January 1, 1997, Social Security Administration guidelines do not include alcoholism or

drug abuse as a qualification for disability status.

6

Patient’s name___________________________________________________________________

7

Date patient became disabled __ __/__ __/__ __ __ __

Month

Day

Year

8

Was the patient able to work for a living after the above date? yes

no

9

Has the disability lasted or is it expected to continue for 12 months or more? yes

no

10

What is the nature of the disability?___________________________________________________

11

Physician’s name_________________________________________________________________

12

Physician’s signature and date___________________________________

__ __/__ __/__ __ __ __

Month

Day

Year

13

Physician’s Illinois

registration number 3 6 - ___ ___ ___ ___ ___ ___

(issued by Illinois Department of Professional Regulation)

-

14

Physician’s phone (____) ___________

Area code

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 REQUIRED. Failure to provide

information could delay your grant and/or pharmaceutical coverage. This form has been approved by the Forms Management Center.

IL-492-3691

Schedule A (IL-1363) (R-12/99)