Illinois Department Of Healthcare And Family Services Medical Application Form (Page 2 of 3) in pdf

Illinois Department Of Healthcare And Family Services Medical Application Form Page 2

PLEASE ATTACH A COPY OF YOUR MOST RECENT STATE INCOME TAX RETURN (FORM IL-1040).

If patient is a minor, and included in parent’s or guardian’s State Income Tax Return.

Patient and members of family living at home – employed during the past year. If patient is a minor,

include parent’s or guardian’s income.

Annual

Current

If Currently Unemployed, State

Name

Place of Employment

Income

Monthly

Why and Last Day of

During Past

Income

Employment

Year

Other Income During Past Year

Unemployment Compensation: $________________ x

______ Months, or $________________ Total

Disability or Pension:

$________________ x

______ Months, or $________________ Total

Social Security Income:

$________________ x

______ Months, or $________________ Total

Other Income:

$________________ x

______ Months, or $________________ Total

Please specify other income:

________________________________________________________________________________________________________

Signature: __________________________________________

Date: ____________________

Day

Year

(Patient signature – If minor, parent or guardian signature)

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

Illinois Department Of Healthcare And Family Services Medical Application Form Page 2