Illinois Department Of Healthcare And Family Services Medical Application Form

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Illinois Department of Healthcare and Family Services
For Office Use Only
ATTN: Hemophilia Program
Identification
P.O. Box 19129
Springfield, IL 62794-9129
Patient Number
APPLICATION TO THE STATE HEMOPHILA PROGRAM
Patient Name:
(First)
(Middle)
(Last)
Mr.
Mrs.
Miss
Date of Birth
Social Security Number
Sex
Male
Female
Patient’s Permanent Address
City
State
Zip code
County
Home Telephone Number
Work Telephone Number
Cell Phone Number
Patient’s Hemophilia Physician
Social Worker Name
Name of Hemophilia Treatment Center
Address of Hemophilia Treatment Center
City
State
Zip code
County
Last Date of Comprehensive Visit
Next Comprehensive Visit
Diagnosis
*An eligible person shall have a complete yearly comprehensive care evaluation in a Hemophilia Treatment Center. A written statement by the
center director indicating that the comprehensive care evaluation has been performed shall be sent to the State Hemophilia Program each year.
Failure to comply will result in the termination from the program. HFS 89 ILLINOIS ADMINISTRATIVE CODE Chapter 1, Section 146.430
Subchapter d Section 146.430
Members of family living in household, including patient. Please list head of household first
Name
Age
Relationship to Patient
Major Medical Insurance and Prescription Drug Information (please include copy of insurance card(s)
Insurance Company Name
Policy Holder
Policy Number - -Group- Individual
Prescription Drug Plan (if separate from Medical Insurance)
Policy Number - -Group- Individual
What percentage does your insurance (or drug plan) pay towards the cost of factor?
Please disclose monthly premium costs
60%
80%
100%
Other
IMPORTANT NOTICE: This State Agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under
Public Act 83-99. Disclosure of this information is mandatory.
I hereby certify that the answers given on this application and financial profile are correct and true to the best of my knowledge. I authorize the Illinois
Hemophilia Program or its representatives to verify all facts herein stated relative to my financial condition or income. I consent to the furnishing by
physicians or hospitals of any information requested by the Illinois Hemophilia Program regarding my diagnosis or treatment. A photocopy of this consent
will be as valid as the original. It is understood that all information will be treated as confidential.
REV 4-1-14

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