Form Hfs 1229a - Nursing Home/supportive Living Facility Redetermination Report
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State of Illinois
6 (Permanent)
Department of Healthcare and Family Services
Department of Human Services
Nursing Home/Supportive Living Facility Redetermination Report Form
Date:
Case Number:
FCRC:
This is an important form. You must answer every question with your current information. We will use your answers to decide
if you still qualify for medical assistance. Send this completed form and all verifications you have to the Illinois Department of
Human Services Family Community Resource Center (FCRC) shown above
by
If you need help providing any verifications or if you have any questions, please call
your caseworker at
If you use a Telephone Device for the Deaf, call
Check Your Answer
Amount / Month
Section A: Income
1. Do you get money from any of the following sources?
a. Social Security
Yes
No
b. Supplementary Security Income
Yes
No
c. Veterans Benefits
Yes
No
Yes
No
d. Railroad Retirement
e. Pension
Yes
No
f. Income From Property
Yes
No
g. Black Lung Benefit
Yes
No
h. Contribution
Yes
No
i. Other
Yes
No
2. Do you get paid for working?
Yes
No
If YES, complete the following information:
Employer Name (If self-employed, enter self)
Address:
How often paid
Value
Section B: Resources
Check Your Answer
1. Do you have any of the following resources?
a. Cash
Yes
No
b. Savings Account
Yes
No
c. Checking Account
Yes
No
d. Nursing Home Resident Account
Yes
No
e. Burial Funds
Yes
No
f. Mutual Funds, Stocks, Bonds
Yes
No
g. Certificates of Deposit
Yes
No
h. Annuities
Yes
No
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HFS 1229A (R-11-12)
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