Illinois Department of Human Services, Division of Developmental Disabilities

Consumer Handbook for Home-Based Services, Children's and Adult Medicaid Waivers


Last Updated June 2018


Table of Contents

  1. I. Introduction
  2. II. What is the Purpose of Home-Based Services?
  3. III. What Services Are Available in the Home-Based Program?
  4. IV. How To Decide Which Services to Select
  5. V. What Are My Responsibilities in Home-Based Services?
  6. VI. Who is Available to Help?
  7. VII. Appendices
  8. A. Definitions
  9. B. Description of Services
  10. C. Person Centered Planning (updated June 2018)
  11. D. Employer of Record Implementation Strategy
  12. E. Home-Based Support Services Service Agreement

I. Introduction

This handbook is designed to help you understand and manage the services available through the Home-Based Services (HBS) program. Your HBS program is provided by the Illinois Department of Human Services/Division of Developmental Disabilities (DDD).

Whether you are currently receiving DDD Home-Based Services or you have recently received notice from the Division of your eligibility to begin services, this Handbook offers information to help you make informed decisions based on your individual needs and desires.

What Changed Effective July 1, 2017?

Effective July 1, 2017, Illinois Medicaid Waiver programs, including HBS, began undergoing some changes based on direction from the federal government, specifically Centers for Medicare and Medicaid Services (CMS). There are three main changes summarized below with short explanations of what they mean to you.

1.  Phasing Out Service Facilitation and Introducing Self-Direction Assistance.

From July 1, 2017 through June 30, 2018, the Division will phase out the title and role of Service Facilitation. HBS participants are no longer required to have a Service Facilitator. This change will occur when the annual planning date for your ISP comes due.

Beginning July 1, 2017, the Division introduced a new service under HBS called Self-Direction Assistance (SDA). An SDA assists the participant (or the participant's family/representative, as appropriate) in arranging for, directing and managing services. Practical skills training is offered to enable families and participants to independently direct and manage waiver services. Examples of skills training include providing information on recruiting and hiring personal support workers, managing workers, and providing information on effective communication and problem-solving. The service/function includes providing information to ensure that participants understand the responsibilities involved with directing their services. The extent of the assistance furnished to the participant or family is to be specified in the Personal Plan.

2.  Conflict of Interest Free Case Management.

Effective July 1, 2017 the ISC agency (who already provides ISSA) will also become your case manager. Case management includes: determining if you are eligible for services, helping you find a provider(s), developing your Personal Plan and monitoring your Plan. "Conflict Free" means that Case Management must be done by someone that is not:

  • your relative
  • a provider agency or someone who works at a provider agency
  • someone who has a financial interest in a provider
  • someone who would benefit from providing you services
3.  Person Centered Planning

This is a process that outlines what is important to a person and what is important for a person. It is a way to record a person's strengths, needs, desires as well as risk. Person Centered Planning has three main parts: the Discovery Tool, the Personal Plan and the Implementation Strategy. For more information on the Person Centered Planning process, see Appendix C.

Your ISC agent will contact you regarding the Person Centered Planning process. By June 30, 2018, this process and documents will replace the Individual Service Plan (ISP). Between July 1, 2017 and June 30, 2018, all people in a DDD Waiver Service will participate in Person Centered Planning.

NOTE: Prior to July 1, 2017, if you were already in the Home-Based Waiver, your services were identified in an Individual Service Plan (ISP). An ISP was developed at an annual meeting where needs and services were documented by your service provider and approved by you. Your ISC was invited to attend that meeting. If you have a current ISP in place, your participation in the new Person Centered Planning process will begin before your next annual meeting date, but no later than June 30, 2018. If you are new to the Home-Based Waiver after July 1, 2017, you will participate in the new Person Centered Planning process before services begin.


II. What is the Purpose of Home-Based Services?

The purpose of Home-Based Services (HBS) is to purchase needed services that will help you continue living safely and successfully in your own home or with your family. HBS is a "self-directed" program in that individuals, guardians and families have the responsibility to arrange and manage their own services and supports.

HBS provides a monthly budget that you can use to purchase needed services and supports, as identified in your Personal Plan. Your HBS monthly budget does not come to you in cash or a check but is a set amount available for you to purchase services. Remember that HBS is to be used for your personal benefit and not for the benefit of your family, guardians or service providers.

  • As a recipient of HBS, you will always have the right to:
    • Be safe;
    • Be treated with respect;
    • Have your choices explained to you in a way you understand;
    • Tell or show others what is important to you, what you want and need;
    • Privacy;
    • Be free from abuse;
    • Speak up and complain if you don't like something;
    • Be told about changes that affect you;
    • Ask questions about any decision that takes services away from you;
    • Ask for a review or appeal on any decisions that deny services or take away your services.

III. What Services Are Available in the Home-Based Program?

The list below contains all the services that are available to you in the HBS program. Please refer to Appendix B for a full description of each service.

Service

Is this

available in Adult HBS?

Is this

available in Children's HBS?

Is this service mandatory? Do I need approval before starting this service? Does this come out of my monthly budget?
Adaptive Equipment YES YES NO YES NO
Adult Day Care YES NO NO YES YES
Assistive Technology YES YES NO YES NO
Behavior Counseling (Individual and Group) YES NO NO NO YES
Behavior Intervention & Treatment YES YES NO NO YES
Community Day Services (formerly known as Developmental Training) YES NO NO NO YES
Emergency Home Response YES NO NO NO YES
Fiscal Employer/Agent YES YES *YES (see note) NO NO
Home Accessibility Modification YES YES NO YES NO
Individual Service and Support Advocacy YES YES YES NO NO
Non-Medical Transportation (HBS only) YES NO NO NO YES
Nursing (HBS only) YES YES NO NO YES
Occupational Therapy YES NO NO YES YES
Out of Home Respite YES YES NO NO NO
Personal Support Worker YES YES NO NO YES
Physical Therapy YES NO NO YES YES
Psychotherapy YES NO NO NO YES
Regular Work/Sheltered Employment YES NO NO YES YES
Self Direction Assistance (HBS only) YES YES NO NO YES
Speech Therapy YES NO NO YES YES
Support Services Team YES NO NO YES NO
Supported Employment YES NO NO YES YES
Temporary Assistance YES YES NO YES NO
Training & Counseling Services for Unpaid Caregivers YES YES NO NO NO
Vehicle Modifications YES YES NO YES NO
  • *NOTE: HBS participants are required to use a Fiscal Agent when hiring personal support workers that are not employees of a provider agency.
  • Programs offered by park districts, health clubs and community colleges do not meet the criteria for Home and Community Based Waiver services and cannot be paid for directly through the HBS program.
  • Both the Children's and Adult HBS programs permit hiring family members to perform PSW duties.  The Children's HBS program does not permit parents or other legally responsible adults to provide PSW services.  The Adult HBS program does permit parents or other legally responsible adults to provide PSW services; but prohibits spouse's or children from providing these services. Community agencies may also offer PSW services on an hourly fee basis.

IV. How To Decide Which Services to Select

Choosing what services to purchase with your Home-Based funds involves three main considerations:

  • Choose services based on your Personal Plan
  • Choose the services that fit within your HBS budget
  • Choose services that are available in your area

A. Choose Services Based on Your Personal Plan

Developing a thorough Personal Plan is the key to identifying what Home-Based services and supports you will need to help achieve your desired outcomes. A good Plan documents what you want and need to continue successfully living in your home; ensures that you, your family or guardians, and any service providers understand and fulfill their roles and responsibilities; and ensures funds are used in your best interests.

The Children's and Adult Home-Based Waivers use a Person Centered Planning approach where you and your family or guardian are key members of a planning team. Other members include your ISC (case manager), current provider agencies and may also include other people you invite to be members of the team, such as potential service providers, other family members, friends or natural supports from within your community.

B. Choose the Services that Fit Within Your HBS Budget

1.  Mix and Match Based on Your Needs, Priorities, and Outcomes

Choose services depending on your needs, and make sure to keep the total costs within your monthly Individual Budget amount. Prioritize your needs and concentrate on finding services and supports for those high priority areas first. Think carefully about how you want to manage your services, and how much control and choice will work best for you. For example, you may choose to use some of your budget to attend a group day program and then use the rest to hire a neighbor to give personal support. Each option comes with different levels of responsibility for you and your family/guardian.

2.  Understand your Monthly Individual Budget

For the Children's Home-Based Waiver and for Adults who are still full-time students, the monthly Individual Budget is two times the individual Supplemental Security Income (SSI) amount. For the Adult Home-Based Waiver (no longer full-time students), the monthly Individual Budget is three times the individual SSI amount.

3.  Understand that Service Costs Vary
  • Although you can negotiate some service costs, most are fixed-rates set by the State of Illinois.
  • The amount that you will pay Personal Support Workers, if you choose to hire your own workers, is negotiated directly between you and the worker. You decide what rate of pay is appropriate based on market conditions, what level of experience or training you want, and hours/days of the week you need workers. You must decide how much to pay per hour and how many hours of service you can afford while remaining within your monthly individual budget.
  • Fees, also called rates, for the other services are established by the State. There is no negotiation allowed for these fees. The current fee or rate for these services can be found at this link: http://www.dhs.state.il.us/page.aspx?item=38992
4.  Establish Service Agreement(s)
  • Ensure a written Service Agreement is completed between the participant and each service provider. Use the IL462-2029 (R-06-17) Home-Based Support Services (HBS) Service Agreement form (which is also found in Appendix E of this Handbook) to do this.
  • The Service Agreement defines the terms of the services to be provided including the effective date, the rate of payment, the maximum units of service to be provided each month and the maximum monthly charge.
  • Update and/or change the Service Agreement as necessary. Provide copies of the revised Service Agreement to the Fiscal Employer Agent.

C. Choose Services That Are Available in Your Area

  • Service providers are located throughout Illinois. However, not all the programs or services you want are within easy driving distance from your home, particularly if you live in a small town or in certain rural areas. There are several ways to check on availability of services.
  • Your ISC agency is usually the best and first source of information about services and providers. The ISC agencies are familiar with service options and provider agencies within your area and can help with information on how to contact them.
  • The DDD also maintains a list of providers who serve individuals with developmental disabilities. This list is available on the DHS website at the following link: http://www.dhs.state.il.us/page.aspx?item=56772
  • You can also ask friends, neighbors, classmates, teachers, therapists, your doctor, faith community, or any of the statewide disability advocacy groups for referrals. Most people recommend you visit each site or service provider in person before making your selections.

V. What Are My Responsibilities in Home-Based Services?

A. Maintain Your Financial Medicaid Eligibility

You must maintain continuous Medicaid eligibility to continue receiving Home-Based Medicaid Waiver services. The Waiver requires a yearly Redetermination that includes documentation of your continued Medicaid eligibility as well as looking at your level of need.

Every year, you will receive two Medicaid Redetermination notices in the mail. The first mailing is a letter notifying you that your Redetermination date is approaching and to watch for the Redetermination Form in approximately two weeks. The second mailing contains the actual Redetermination Form which you need to complete, attach any verifications and/or documentation requested, sign, and return by the deadline date indicated in your letter.

Watch for mail with a return address from your Family and Community Resource Center (FCRC) or the Illinois Medicaid Redetermination Project (IMRP). These are the two Illinois entities which handle Redeterminations.

It is crucial that you watch for, complete, and return your Medicaid Redetermination Form within the specified time frames, or you may lose your Medicaid status and be ineligible for HBS. This means that any Personal Support Worker paychecks or reimbursement checks to other service providers or agencies may stop.

If you have any questions or concerns about Medicaid Redetermination, follow the instructions included in your letters or call your ISC agency.

The Illinois Medication Redetermination Project has also created a list of Frequently Asked Questions and Answers: https://www.Illinois.gov/hfs/SiteCollectionDocuments/EEVClientFAQ042315.pdf

B. Manage Your Services

  • Educate yourself about HBS rules, procedures and forms. Keep this Handbook and any other documentation you need related to your PSWs or other service providers in a place where you can access them easily.
  • Educate yourself by starting with this list of Home-Based resources compiled by topic, responsible state agency, web page links, and Division contacts: http://www.dhs.state.il.us/page.aspx?item=93852. The Division maintains consumer webpages with information about many HBS topics.
  • Manage your individual budget wisely to avoid spending more than you have. If you spend more than what is provided for you, someone will not get paid.
  • Maintain communication with your ISC, FE/A, and your other providers. Respond promptly to phone calls and requests for information.
  • Complete and submit time sheets and other required paperwork on timely basis.

If at any time, you or your family/guardian feel that you cannot uphold these responsibilities, you may voluntarily request Self-Direction Assistance. Contact your ISC to begin this process if you decide to do so.

C. Report Occurrences of Abuse, Neglect or Exploitation

Any type of serious or dangerous incident must be reported. Anyone, this includes you, your family/guardian, your ISC, SDA, or anyone you trust, may make a report if something bad happens to you. A serious or dangerous incident means someone has hurt you, called you names, left you alone, didn't take care of you, stole your money, or did other bad things. If you are away at work or at a day program, the service provider must report the incident.

How Do I Make a Report?

To make a report for a person under age 18, call the Department of Children and Family Services 24-hour hotline at 800-252-2873.

To make a report for a person 18 years of age and over for an incident that happened outside the home, call the DHS Office of Inspector General's 24-hour hotline at 800-368-1463 or 800-447-6404 TTY.

To make a report for a person 18 years of age and over for anything that happens in the home call the Department of Aging Adult Protective Services Hotline at 866-800-1409 or 888-206-1327 TTY.

D. Update Your ISC Agency

Keep your ISC up-to-date on any significant changes to your life or your needs. This can be done by phone, email or during a regularly scheduled visit. Let them know if anything has happened in your life that may affect your needs for services and supports. You should also let them know if you've changed your mind about what services you want or need. Let them know about new significant health issues, changes in prescription medication, health issues with a primary caregiver, if your Personal Support Worker resigns or quits, if you move, get a new job or lose your current job.

You, your family/guardian, PSW workers, or any service providers who work for you must immediately report to your ISC if any of these things happen to you:

  • Injuries or death
  • Hospitalization for an unplanned reason
  • If you are lost or missing and the police have been called
  • If you are arrested, have legal charges or jailed
  • If someone has stolen from you or hurt you physically
  • If you need to be restrained

In the event of an immediate crisis, call 911 and then contact your ISC agency as soon as possible. Each ISC has a 24-hour emergency hotline number which you can call at any time of the day or night. Your ISC can help you understand what additional, short-term, emergency services may be available to help.

E. Ensure HBS Supports Are Used Appropriately

Home-Based Waiver Services are designed to support you in making progress toward and reaching desired outcomes, as documented in your Personal Plan. Services are also designed to keep you safe and well, in your home or community. Funds are to be used for your support and needs not to help your family or friends. In rare cases, Involuntary Termination of Self-Directed Home-Based Services may be filed if:

  • You or your family/guardian is found to have committed fraud regarding use of funds.
  • You are found to be living with a family member or other individuals who have been determined by Adult Protective Services or other authorized law enforcement entity to have abused or neglected you or other individuals.
  • The ISC and Fiscal Employer Agency have determined and documented that you or your family/guardian are not able to satisfactorily direct your own services, either with or without the help of a Self-Directed Assistant (SDA.)
  • Family/guardian has been found to be acting in his/her own interest rather than in your best interests and no other guardian or representative is willing to take on this responsibility.

In cases of suspected fraud, abuse, neglect, or financial exploitation, your ISC agency can help you file a complaint. The form used is the Rights of Individuals Form: http://www.dhs.state.il.us/onenetlibrary/12/documents/Forms/IL462-1201.pdf

If you have been denied eligibility or services, been terminated, suspended, or received a reduction of waiver-funded services, you have the right to ask that this decision be reconsidered. This is called the Right to Appeal. For more information on your appeal rights access the following link: http://www.dhs.state.il.us/onenetlibrary/12/documents/Forms/IL462-1202.pdf


VI. Who is Available to Help?

If you need more information or guidance about any part of the Home-Based Services program, your sources of support include your:

  • Independent Service Coordination (ISC) Agency
  • Fiscal/Employer Agent (F/EA)
  • Self-Direction Assistance (SDA)
  • Natural Supports

A. Independent Service Coordination (ISC) Agency

Your Independent Service Coordination (ISC) agency staff is your partner in almost every aspect of establishing and managing your services. The service coordinator is involved in the development of the Discovery Tool and Personal Plan; they also monitor your services as well as your general health, safety and well-being.

There are currently 17 ISC agencies serving Illinois, divided by counties. They are the same agency with whom you processed your eligibility screening and PUNS Waiting List application when applying for Home-Based Funding. Find your ISC agency contact information by clicking on this link: http://www.dhs.state.il.us/page.aspx?module=12&officetype=&county=

Once you are enrolled in a DD Waiver, the ISC agency staff will provide Individual Service and Support Advocacy (ISSA) services; see section VII, B for a description of ISSA services).  You may contact them at any time to present a complaint or discuss unresolved issues or problems affecting your health and welfare. The ISC agency staff will work with you to resolve grievances or complaints, particularly those between you and service providers. If the grievance continues, ISC agency staff will continue the process by involving provider staff of increasing authority, up to and including the executive director of the provider agency. If the grievance cannot be resolved, ISC agency staff may help you find a new provider or contact DHS staff for technical assistance or intervention.

B. Fiscal/Employer Agent (F/EA)

If you and your family choose to hire personal support workers (PSWs) directly, the F/EA will assist with the entire hiring process and be available for consultation if questions arise.

The Division contracts with two Fiscal/Employer Agent (F/EA) companies that handle Personal Support Worker employment functions such as pre-employment testing, new hire paperwork and payroll and tax functions. If you choose to hire your own PSWs, you must select one of these two companies to assist with questions about PSWs.

Avenues to Consumer Employer Services and $supports (ACES$)

2960 Baker Drive

Springfield, IL 62703

Contact: Tasha Whiteside

Phone: 877-223-7781

Fax: 217-528-9849

Email: twhiteside@mycil.org

Website: www.mycil.org

OR

Public Partnership, LLC (PPL)

One Cabot Drive, Suite 102

Medford, MA 02155

Contact: Customer Services -

Illinois DD Project

Toll free phone: 888-866-0582

Fax: 866-826-7287

Email: ildd@pcgus.com

Website: www.publicpartnerships.com

C. Self-Direction Assistance (SDA)

Self-Direction Assistance (SDA) is an optional waiver service you can purchase and is available in both the Children's and Adult Home-Based Waivers.

The Self-Direction Assistant is an employee of a licensed community service provider who can help guide you in arranging for, directing, and managing Personal Support Worker (PSW) services. They can also provide skills training designed to help you better recruit and hire PSWs, as well as provide information on effective communication and problem-solving skills.

Ask your ISC for a list of providers in your area who offer Self-Direction Assistance.

D. Natural Supports

Last, but certainly not least, your friends, family, and other people you know can help - these are your natural supports. They can help you plan and implement your services. They can also share their ideas, information and personal experiences. Natural supports are an important part of everyone's life.


VII. Appendices

A. Definitions

Term Definition
Appeal Rights If you have been denied eligibility, services, or have been terminated, suspended or received a reduction of waiver-funded services, you have the right to ask that this decision be reconsidered.
Assessment An assessment is a test or evaluation completed by a professional qualified in an area of expertise. Assessments help accurately determine your levels of independence or supports needed to ensure your safety and well-being.
Adult Waiver A program for adults, age 18 and over, with Developmental Disabilities that provides support to prevent or delay out-of-home residential services or to provide residential services in the least restrictive community setting for individuals who would otherwise need ICF/DD level of care. 
Centers for Medicare and Medicaid Services (CMS) The federal agency within the Department of Health and Human Services, which reviews, approves and monitors State Medicaid Waiver plans.
Children's Support Waiver Provides Home-Based services and supports to children and young adults with developmental disabilities ages 3 through 21 who live in their family home. Young adults, age 18-21, who are enrolled in the Children's Support Waiver must be full-time students. Families are allowed to purchase services and supports within a monthly spending maximum equal to two times the Supplemental Security Income (SSI) amount.
Conflict of Interest Free Case Management The Federal government regulations require States to separate case management from service delivery. Case Management cannot be done by someone who: is a relative of the person served, is a direct provider of service, has a financial interest in a provider, or is employed by a provider. Case managers perform eligibility determinations, develop the Personal Plan, help families find providers, and monitors services. eligibility determinations, develop Personal Plan, help families find providers, and monitors services.
DHS Family Community Resource Center The local office that you contact to apply for Medicaid. Find your local office here: DHS Office Locator
Discovery Tool A document that the ISC use in the Person Centered Planning process to gather information on what is important to and important for a person. The Tool addresses 10 life areas. It is designed to lead conversations about a person's preferences, strengths, needs, barriers and risk that are present. This information is used to develop the Personal Plan.
Employer of Record HBS participant and/or legal representative, family or close associate who is responsible for overseeing the services outlined in the monthly budget, signing Service Authorizations and signing PSW time sheets. The Employer of Record is responsible for hiring, training, ensuring competency, supervising and firing PSWs. For the Adult Waiver, per the Internal Revenue Service, the same person cannot be both Employer of Record and a PSW hired by the family.
Fiscal/Employer Agent (F/EA)

Companies contracted by the State to help Home-Based Services Waiver participants hire Personal Support Workers which can include background checks, payroll taxes, insurance, completing paperwork, and paying workers out of your budgets.

In Illinois, the two state-contracted F/EAs are ACES$ (Avenues to Consumer Employer Services and $supports) and PPL (Public Partnership, LLC).

Home and Community-Based Services (HCBS) Waivers The HCBS Waivers fund services that prevent or delay living in a long-term care facility. Illinois operates three HCBS Waivers for people with developmental disabilities: the Adult Waiver, the Children's Residential Waiver and the Children's Support Waiver.
Illinois Department of Healthcare and Family Services (HFS) The single Illinois state Medicaid agency that oversees waiver programs including the three Developmental Disability Waivers: the Adult Waiver, the Children's Residential Waiver and the Children's Support Waiver.
Illinois Department of Human Services (DHS), Division of Developmental Disabilities (Division or DDD) The state agency in charge of developmental disabilities services, including the Children's and Adult Home-Based Services.
Implementation Strategy A document, created by service providers or the Employer of Record, that describes how your service providers will support the outcomes and needs documented in your Personal Plan. This is a part of the Person Centered Planning process.
Independent Service Coordination (ISC) Agency As the case management entity, ISCs maintain the DDD's waiting list, determines clinical eligibility, assist with identifying providers of choice, develop the Personal Plan and monitors the Plan. ISCs serve as the front line for information and assistance to help individuals and families make informed choices and to navigate the system. The Division currently funds 17 ISC agencies across the State.
Individual Service and Support Advocacy (ISSA) ISSA is one of the four services that ISCs provide. When performing ISSA, ISCs helps you understand and make choices, works with you to develop your Discovery and Personal Plan, refers you to area service providers, monitors services, helps resolve issues and makes sure your rights are respected. 
Qualified Intellectual Disability Professional (QIDP) A professional staff with experience in the field of intellectual/developmental disabilities. A QIDP must meet academic and clinical standards established by the federal government and training requirements established by the State of Illinois.
Medicaid Re-Determination (clinical) Evaluates your eligibility to continue receiving Medicaid services. Requires you and your family/guardian to complete and return a Re-Determination form each year to the state Medicaid agency, documenting your continued eligibility for Medicaid, so that you can continue receiving Home-Based Services.
Pre-Admission Screening (PAS) A Pre-Admission Screening is one of the four services that ISCs provide. A PAS assessment is required by the Federal Medicaid agency to determine that the individual has a developmental disability or related condition and is likely eligible to receive services.
Person Centered Planning A process to document the balance between what is important to a person and what is important for a person. It also identifies strengths, preferences, needs (both clinical and support needs) and risk of a person. In Illinois, it has 3 main parts: Discovery Tool, Personal Plan, and Implementation Strategies.
Personal Plan The second major part of the Person Centered Planning Process. A written vision for your life focusing on your strengths, preferences, needs and desires. The Independent Service Coordination (ISC) agencies develop your Personal Plan along with you, family/guardian, and anyone else you wish to invite. The Personal Plan contains the outcomes you want, providers you select to help you achieve those outcomes, barriers, risk factors and plans to minimize the risk.
Personal Support Worker (PSW) A Personal Support Worker is an individual hired either by you and your family/guardian, if one has been appointed, or someone who is hired by a service provider agency. PSWs may assist with activities of daily living, supervision, or teaching skills that promote your safety and well-being, either at home or out in the community.
Self-Direction Assistance (SDA) Optional service you can purchase to equip you to employ, train, supervise and manage non-agency based PSWs.You can also purchase SDA services to help you develop your Implementation Strategy.

B. Description of Services

HBS offers a variety of services to help individuals live a full and productive life. This section offers a description of each of the services available in Home-Based Services.

 Adaptive Equipment

  • Adaptive equipment, as specified in the Personal Plan, includes:
    • Assessments to identify the type of equipment you need;
    • Devices, controls or appliances that enable you to increase your abilities to perform activities of daily living, or to control, access or communicate with the environment in which you live;
    • Other durable medical equipment not available under the Medicaid State Plan that is necessary to address any functional limitations;
    • Necessary initial training from the vendor about how to use the adaptive equipment. 
  • Adaptive equipment may also include necessary maintenance and repairs to adaptive equipment.
  • Items reimbursed with Waiver funds are separate and in addition to any medical equipment and supplies furnished under the Medicaid State Plan.  Those items not of direct remedial benefit to you are excluded. All items shall meet applicable standards of manufacture, design and installation. Some examples of covered adaptive equipment include reachers; grabbers; voice-activated, motion-activated and electronic devices; and specialized computer software.
  • Lift chair mechanisms, communication devices and mobility devices may be covered if not covered by the Medicaid State Plan. Some examples of adaptive equipment that is not covered include furniture, recreational or quality of life items, such as televisions, stereos, boom boxes, fitness equipment, microwave ovens and other general appliances.
  • Medical equipment and supplies are not considered adaptive equipment.
  • There is no charge to your monthly budget for this service.

Adult Day Care

  • Adult day care is available if you are aged 60 and older.
  • Individuals not yet 60 may also be served if day habilitation or employment services are determined not to be appropriate because of a medically fragile condition.
  • Adult day care services are generally furnished four or more hours per day on a regularly scheduled basis, for one or more days per week, or as specified in the Personal Plan, in a non-institutional, community-based setting, encompassing both health and social services needed to ensure your optimal functioning.
  • The cost for this service comes from your monthly budget.

Assistive Technology

  • Assistive technology devices are items, pieces of equipment, or product systems, whether acquired commercially, modified, or customized, used to increase, maintain, or improve functional capabilities.
  • Assistive technology services directly assist you in the selection, acquisition, or use of an assistive technology device. Assistive technology includes the following: evaluation of your assistive technology needs, including a functional evaluation of the impact to determine the appropriate assistive technology and services for you in your environments.
  • There is no charge to your monthly budget for this service.

Behavior Counseling (Individual and Group)

  • Behavior Counseling is a treatment approach in which licensed professionals meet with one or more individuals in ongoing periodic formal sessions, and uses relationship skills to promote your abilities to deal with daily living issues associated with any emotional, cognitive or behavioral problems using a variety of supportive and re-education techniques.
  • Your Personal Plan and Implementation Strategies must include documentation of the need for behavior counseling and the services to be provided by the licensed professional.
  • Behavioral Strategies must be developed and approved in writing by your service provider within 45 days of initial contact.
  • The fee for this service will come from your monthly budget.

Behavior Intervention and Treatment

  • Behavior intervention and treatment includes a variety of individualized, behaviorally-based treatment models consistent with best practice and research on effectiveness that are directly related to your therapeutic goals.
  • Behavior Interventions include: An approach tailored to address your specific behavioral needs; Targeted skills that are broken into small, attainable tasks; Training of direct support staff, informal caregiver and family so that skills can be generalized and communication promoted, especially in the areas of prevention, intervention and stabilization.
  • Services must be directly related to the outcomes contained in your Personal Plan and, if applicable, coordinated with the your Individual Education Plan (IEP). To receive behavior services under the waivers, the services must be based on behavioral assessments documenting the ongoing need for the service and be included in the Personal Plan.
  • The fee for this service will come from your monthly budget.

Community Day Services (formerly known as Developmental Training)

  • Community Day Services provide assistance with acquisition, retention, or improvement in self-help, socialization and adaptive skills.
  • This service takes place in a non-residential setting, separate from your private residence or other residential living arrangement.
  • Activities and environments are designed to foster skill development, appropriate behavior, greater independence, and personal choice.
  • Community Day Services focuses on enabling you to attain or maintain your maximum functional level.
  • The fee for this service will come from your monthly budget.

Emergency Home Response Services

  • Emergency Home Response Services are limited to adults who:
    • live alone, 
    • live with family and are alone for significant parts of the day,
    • who have no regular caregiver for extended periods of time, who would otherwise require extensive routine supervision.
  • Emergency home response service (EHRS) is an electronic device that enables you to secure help in an emergency. You may also wear a portable "help" button to allow for mobility. The system is connected to your phone and programmed to signal a response center once a "help" button is activated.
  • Installation, upkeep and maintenance of devices/systems may be provided.
  • The fee for this service will come from your monthly budget.

Fiscal/Employer Agent

  • If your family chooses to hire your own Personal Support Workers (PSWs), you are required to work with a fiscal/employer agent (F/EA). The F/EAs are private companies that the Division has selected to assist Home-Based families with background checks, tax, and payroll functions.
  • There are currently two FE/A companies in IL from which you may choose, Aces$ Financial Services or PPL.
    • ACES$ Financial Services: 1-877-223-7781
    • Public Partnership, LLC (PPL): 1-888-866-0582
  • The F/EA performs background checks on your potential employee(s), completes initial tax forms and other forms for your worker(s), and then pays your worker(s) twice per month.
  • If your family chooses to hire your own PSWs, an Employer of Record must also be designated. This person is ultimately responsible for managing the employees and ensuring applicable labor laws are upheld. The F/EA will assist you with the entire hiring process and be available for consultation if questions about workers arise.
  • There is no charge to your monthly budget for F/EA service.

Habilitative Therapies (Physical, Occupational, Speech)

  • Physical therapy, occupational therapy and speech therapy for restorative purposes are covered under the Medicaid State Plan for Children and Adults.
  • Adult Waiver participants are eligible for additional physical, occupational and speech therapy services of a habilitative nature. 
  • You must obtain approval before using these services.
  • The need for each of the therapies must be documented in the Personal Plan. 
  • Provider agencies will develop Implementation Strategies or use their existing evaluation and treatment documents.  In either case, the information must include documentation of your specific therapy needs and the specific services to be provided by the licensed professional. 
  • Long-term habilitative physical therapy, occupational therapy and speech therapy services should assist you, family members, direct support workers and others to incorporate effective therapeutic activities in daily life rather than focus on intensive professional treatments focused on short-term acute restorative needs.
  • The fee for these services will come from your monthly budget.

Home Accessibility Modifications

  • Home Accessibility Modifications include those physical adaptations to the private residence of you or your family. Home accessibility modifications should enable you to function with greater independence in the home and includes necessary repair to the adaptations.
  • Home accessibility modifications may be either permanent or temporary. Permanent home modifications are either structural modifications or items that are attached to the home.
  • All services must be provided in accordance with applicable State or local building codes.
  • Examples of home accessibility modifications include:
    • Ramps;
    • Lifts/elevators necessary to enter or leave the home or to access a bedroom or a bathroom, including porch or stair lifts and hydraulic, manual or electric lifts;
    • Bathroom modifications, including roll-in showers, sink modifications, bathtub modifications, toilet modifications, grab bars, adapted water faucet controls, floor urinal and bidet adaptations and plumbing modifications and turnaround space adaptations;
    • Widening of doorways/hallways (may include minimally necessary floor covering to cover the new floor area);
    • Specialized accessibility/safety adaptations/additions including grab bars; necessary handrails beyond those normally required by building codes; lowered or adaptive door handles;
    • Adapted fire alarms, sprinklers, smoke detectors and doorbells; automatic door openers/doorbells;
    • Voice-activated, light-activated, motion-activated and electronically-activated devices;
    • Fire safety adaptations; and electrical wiring associated with the above.
  • There is no charge to your monthly budget for Home Accessibility Modifications.

Individual Service and Support Advocacy (ISSA)

ISSA is one of the services ISC agencies provide.  It is only providing to individuals receiving a DD Waiver service.  When receiving ISSA, ISC agency staff represent your interests in determining whether waiver services are being provided based on your Personal Plan. In addition to developing your Personal Plan, ISC agency staff will conduct at least one monitoring visit each year to ensure you are receiving the services outlined in your Plan.  They alert you and the Division when additional monitoring, intervention or technical assistance is necessary. ISSA services provide support to you, your guardians, and providers in working through a variety of service issues, including those requiring conflict resolution, increased communication, and possible changes in services or support.

  • Additionally, ISSA services provides you and your guardian, if one has been appointed, information about protections from abuse, neglect, and exploitation. The information includes the process for reporting allegations to the Department of Children and Family Services hotline for children through the age of 17, as well as the process for reporting allegations to the DHS Office of the Inspector General, for adults aged 18 and older. You are also informed that if anyone suspects abuse, neglect or exploitation, they also may report an allegation. Information is presented both verbally and in writing.
  • ISSA services are designed to assist but not replace the guardian and other appropriate advocates. You may contact your ISC agency staff at any time to present a complaint or discuss unresolved issues or problems affecting your health and welfare.  They will work with you to resolve grievances or complaints, particularly those between you and service providers. If the grievance continues, they will continue the process by involving provider staff of increasing authority, up to and including the executive director of the direct service provider. If the grievance cannot be resolved, ISC agency staff may contact DHS staff for technical assistance or intervention.
  • Find your ISC agency contact information at the following link: http://www.dhs.state.il.us/page.aspx?module=12&officetype=&county=
  • There is no charge to your monthly budget for ISSA services.

Nursing

  • Nursing services are available within the monthly maximum for Adult DD Waiver participants who are authorized for Home-Based Support Services.
  • These services are in addition to any Medicaid State Plan nursing services for which the participant may qualify.  Nursing services must be listed in the Personal Plan and be within the scope of the Illinois Nursing and Advanced Practice Nursing Act (225 ILSC 65).
  • Nursing services can be provided by a Professional Registered Nurse licensed to practice in the State of Illinois or a Licensed Practical Nurse under the direction of a Registered Nurse who is licensed to practice in the State of Illinois.
  • The fee for this service will come from your monthly budget.

Personal Support Worker

Personal Support Workers are one of the most popular service categories in the Home-Based Waiver for Children and Adults. Typical services provided by PSWs include: Teaching adaptive skills to assist you to reach personal goals within your home or community; personal assistance in activities of daily living; helping you access age-appropriate community places, recreation, leisure, or volunteer activities; and services provided on a short-term basis because of the absence or need for relief of the primary caregivers.

  • PSWs can NOT provide one-to-one supports in an adult day program or at school.
  • Families can hire PSWs through a provider agency, hire their own PSWs or use both.
    • PSWs hired by an agency (Agency-Based PSWs): Some providers recruit, hire and train their own staff. The agency's staff then comes to your home and provides PSW services. The agency sets the hourly wage for their PSWs, there are no wage negotiations.
    • PSWs hired directly by the individual, family or guardian: The individual, family or guardian finds, recruits and manages the PSW. You determine the amount of pay, ensure that all pre-employment and payroll matters are completed, respond to billing questions and oversee your overall budget. You take responsibility for all employer-related duties for Personal Support Worker services. If you hire your own PSWs, you must identify an employer of record, and you must select an F/EA.
  • The Employer of Record is the person who is ultimately responsible for ensuring wages are paid and taxes are filed. They are also responsible for overseeing the services outlined in the monthly budget, sign Service Agreements and Service Authorizations, and time sheets. In addition, the employer of record may help with hiring, training, supervising and firing PSWs.
  • The Employer of Record can be you (if you do not have a guardian), a guardian (as long as they are not also your PSW), or other adult members of your family or a trusted associate. The Employer of Record can be the same person who is your Representative Payee for Social Security benefits.
  • If you hire your own PSW(s), you must select one of two Fiscal/Employer agents (F/EA) chosen by DDD. F/EAs will process PSW paychecks every two weeks according to a predetermined schedule. F/EAs will also withhold and file payroll taxes. Annually, they also send out required federal and state Internal Revenue tax forms to anyone who has worked for you in the capacity of a PSW during the past year. For more details, see the F/EA description in this section.
  • If you want help hiring, managing, and training the workers you have directly hired, you should consider purchasing services from a Self-Direction Assistance (SDA) provider. They can help you in many ways with your own PSWs. There is a description of SDA services in this section.
  • Personal Support Worker candidates MUST:
    • Be at least 18 years of age;
    • Pass required background checks (Criminal Background, Health Care Worker Registry, IL Sex Offender Registry, HFS OIG Sanctions List, and DCFS State Central Registry);
    • Communicate well with you and your family;
    • Complete required paperwork accurately;
    • Understand waiver rules on abuse and neglect; human rights; confidentiality; handling fire and other emergencies; and allowable behavior management methods;
    • Show that they can safely support you, as documented in your Personal Plan.
  • Personal Support Workers CANNOT Be:
    • A person who has hurt children or other people with disabilities;
    • The person receiving DD Waiver services;
    • The husband or wife of someone receiving DD Waiver Services;
    • Your mother or father, if you are in the Children's Waiver;
    • Under 18 years of age.
  • The fee for Personal Support Workers will come from your monthly budget.

Pre-Admission Screen

Individual Service Coordination (ISC) agencies conduct Pre-Admission Screenings (PAS) to determine if you are eligible for DD Waiver Services. This is just one of the services that ISC agencies provide and is required by the Federal Medicaid agency. If you are currently enrolled in Home Based Services, this screen has already been completed. 

  • When conducting a PAS, the ISC agency staff will:
    • Complete or obtain assessments from licensed, certified, or registered professionals (such as doctors and psychologist).
    • Determine whether you have a developmental disability.
    • Determine whether you need 24-hour nursing care and/or ongoing supports and training in daily living skills.
    • Identify your service and support needs.
    • Determine if you need someone to help make major decisions and take on the role of guardian.
    • Present you with information so that you can make informed choices; assist with making referrals to providers or other entities and inform you of your right to appeal their determinations.
  • There is no charge to your monthly budget for PAS services.

Psychotherapy (Individual and Group)

  • Psychotherapy is a treatment approach in which a licensed professional conducts formal sessions with one or more individuals.  The goal is to eliminate or reduce the symptoms of emotional, cognitive or behavioral disorders. Psychotherapy should also promote positive emotional, cognitive and behavioral development.
  • The Personal Plan must include documentation of your need for psychotherapy and the services to be provided by the licensed professional.
  • The fee for this service will come from your monthly budget.

Regular Work/Sheltered Employment

  • Regular Work/Sheltered Employment provides long-term paid work in an environment that include mostly people with disabilities. 
  • Regular Work/Sheltered Employment provides general work supervision, including direction and on-the-job training in such areas as work expectations, workplace behavior, and compliance to workplace safety standards, production and task completion.
  • Participating in Regular Work/Sheltered Employment does not prevent moving into a Supported Employment position or a competitive employment position.
  • The fee for this service will come from your monthly budget.

Self-Direction Assistance

  • Self-Direction Assistance (SDA) trains you (or your family/representative, as appropriate) in the process of finding, interviewing, hiring, and managing Personal Support Workers (PSWs) who will meet your specific needs. SDAs can teach you the skills to recruit, interview, manage and troubleshoot issues that arise with your PSW. The SDA can also train you on to complete the documents needed when hiring and paying PSWs.
  • The fee paid to the SDA will come from your monthly budget. The SDA hourly rate is set by DDD.

Supported Employment

  • Supported Employment services (SEP) consist of intensive, ongoing supports that enable you to find and gain competitive employment, at or above the minimum wage, if you would be unable to achieve that without supports.
  • Generally conducted in a variety of settings, particularly work sites where persons without disabilities are employed.
  • SEP also includes ongoing supports you may need with accommodations, conflict resolution or problem-solving on the job, to successfully maintain employment. 
  • The fee for this service will come from your monthly budget.

Temporary Assistance

  • Temporary Assistance (TA) are personal support services provided on a temporary emergency basis because the person who usually assists you and provides unpaid care (primary caregiver) - is absent or incapacitated.
  • Absence or incapacity of the primary caregivers must be due to a temporary cause, such as hospitalization, illness, injury or another emergency.
  • There is no charge to your monthly budget for Temporary Assistance. Temporary Assistance has a separate maximum of $2,000 per month for two consecutive months (60 consecutive days) for a total maximum of $4,000. 

Training and Counseling for Unpaid Caregivers

  • This service includes training and counseling for caregivers who provide unpaid support to you.
  • For purposes of this service, an unpaid caregiver is defined as any person (family member, neighbor, friend, companion, or co-worker) who provides care, training, guidance, companionship, supervision or support and is not paid through the Home Based funds.
  • Personal Support Workers who are paid through the Home Based funds can not use this service.
  • Training includes instruction about supports and services in your Personal Plan (i.e. use of adaptive equipment) and updates as necessary to safely maintain you at home. Counseling must be aimed at assisting the unpaid caregiver in meeting your needs. All training for individuals who provide unpaid support to the participant must be included in your Personal Plan.
  • The training and/or counseling provided to your unpaid caregiver must be directly related to their role in supporting you as specified in your Personal Plan.  These service should assist your unpaid caregiver to understand and address your specific needs.
  • There is no charge to your monthly budget for this service.

Transportation (Non-Medical)

  • Non-Medical transportation includes services that enable you to gain access to waiver and other community services, activities and resources specified by the Personal Plan.
  • This service is offered in addition to Medical Transportation Services (available under the Medicaid State Plan) and must not replace them. Whenever possible, you should use family, neighbors, friends or community agencies which can provide this service without charge.
  • Transportation to/from services covered under your Medicaid State Plan and transportation to/from day program can not be paid for through this service. 
  • The fee for this service will come from your monthly budget.

Vehicle Modifications

  • Vehicle Modifications are adaptations/changes to an automobile that is your primary means of transportation.  Vehicle modifications are specific to your individual need; they should support you to access your community and ensure your safety. 
  • The need for Vehicle Modifications must be specified in the Personal Plan.
  • Examples of vehicle modifications include adaptations/changes to:
    • Lifts or ramps;
    • Doors;
    • Seating;
    • Safety/security;
    • Inside height.
  • The following are not allowed as a vehicle modification:
    • Adaptations or improvements to the vehicle that are of general utility, and are not of direct benefit to you;
    • Purchase or lease of a vehicle;
    • Regularly scheduled upkeep and maintenance of a vehicle except upkeep and maintenance of the modification(s).
    • There is no charge to your monthly budget for Vehicle Modifications.

C. Person Centered Planning (updated June 2018)

Person Centered Planning is the balance between what is important to you and what is important for you. It identifies your strengths, preferences, needs as well as risks. Person Centered Planning also helps you prioritize your outcomes. You can include anyone you want to be a part of your Person Centered Planning process.

Person Centered Planning must:

  • Be driven by you
  • Ensure services are provided to you in a manner that reflects your preferences and needs
  • Include evidence that you chose the places and types of services you are receiving
  • Assist you to achieve the outcomes you choose and in the most integrated setting
  • If you want to work, include opportunities for you to seek employment and work in competitive jobs that people without disabilities work in.
  • Include opportunities for you to be a part of your community, have control over your money and property. You should also have opportunities to get services in the community just as people who do not have a disability.
  • Be written in plain language that you and your family/guardian can understand
  • Include things that are important to you about your culture (for example: how you celebrate holidays)
  • Include strategies for solving disagreements

The Person Centered Planning process developed for the Illinois' Developmental Disability system, including Home-Based Services, consists of the three main parts explained below:

1.  The Discovery Tool & Process

The Discovery Tool is a form the ISC will use to collect information about what you want, need, like, dislike, and include your strengths and risks that are present in your life. The ISC will complete this document with you, your guardian (if you have one) and anyone else you want. They will also get information from any provider agency that is currently serving you.

The Discovery process is not necessarily a one-time event or meeting rather is an information gathering process. The ISC can gather information through face-to-face, phone, or electronic discussions. They can also gather information by observation and reviewing records, evaluations, assessments and/or case notes. Information gathered during this process is used to develop your Personal Plan. This information will also be shared with provider agencies that you choose.

The Discovery Tool is available at this link: http://www.dhs.state.il.us/OneNetLibrary/27896/documents/Discovery Tool.pdf

2.  The Personal Plan

Once the Discovery Tool is complete, your ISC will use this information to develop your Personal Plan. The Personal Plan is a document that outlines what you want your life to look like. This document is also sent to provider agencies that serve you or those you want to serve you.

The Personal Plan focuses on your strengths, preferences, needs and outcomes. It reflects your preferences in how services are delivered to you, where, when and by whom. It will include your choice of providers if you have made them. It also documents any risk to your personal health, safety, and well-being along with plans necessary to lessen these risks.

You and your family/guardian will have an opportunity to review and approve the Personal Plan to ensure it has accurately captured and highlighted the information you feel is essential about you. This document is also sent to provider agencies that serve you or those you want to serve you.

The Personal Plan format is available at the following link: http://www.dhs.state.il.us/OneNetLibrary/27896/documents/PersonalPlan.pdf

3.  Implementation Strategies

  • Now that the Personal Plan is complete, the last major part of the Person Centered Planning process is the Implementation Strategies. The information identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy. An Implementation Strategy must detail the services and supports that will be provided on a day-to-day basis.
  • Provider Agencies Implementation Strategy (this section was updated June 2018)
  • If you want to use services from a DD agency, the ISC will assist you to find agencies that are willing and able to provide you services. Once you have located an agency(s) and they agree to meet your needs, some provider agencies (see chart below) will develop an Implementation Strategy. Once complete, they will send you, your guardian and ISC a copy to review.  If you have questions you should contact the agency or your ISC. Information on the Provider Implementation Strategy is available at the following link: http://www.dhs.state.il.us/OneNetLibrary/27896/documents/By_Division/Division%20of%20DD/LifeChoices/ImplementationPowerPointHandout060517.pdf
    •  
    • The following services require an Implementation Strategy:

      • Adult Day Care
      • Agency-based Personal Support Worker (HBS only)
      • Child Group Home
      • Community Integrated Living Arrangement
      • Community Day Services (formerly known as Developmental Training)
      • Community Living Facility 
      • Supported Employment Program

      The following services require an Implementation Strategy OR  current Assessment/Treatment Documents:

      • Behavior Counseling
      • Nursing (HBS only)
      • Occupational Therapy
      • Physical Therapy
      • Psychotherapist
      • Speech Therapy

      The following service do not required

      an Implementation Strategy

      • Adaptive Equipment
      • Assistive Technology
      • Home Modifications
      • Non-Medical Transportation (HBS only)
      • Self-Direction Assistance (HBS only)
      • Vehicle Modifications
    • Employer of Record Implementation Strategy
    • Program participants, family, and others who act as the Employer of Record in HBS, must develop an Implementation Strategy. This Implementation Strategy will look different from the one provider agencies develop. The Employer of Record will use the form IL462-1240 (pdf) to develop their Implementation Strategy.  If you are hiring PSWs directly and need help completing your Implementation Strategy, you can purchase Self-Direction Assistance (SDA). Your ISC can help you locate an agency that provides SDA.
    • The Employer of Record's Implementation Strategy must:
    • Be completed using the Employer of Record Implementation Strategy for HBS form and instructions that will be provided.
    • Be completed by the HBS Employer of Record for the person receiving DD Waiver services. If you choose, you can hire a SDA to assist you in completing the Employer of Record Implementation Strategy.
    • Be completed by the HBS Employer of Record anytime the individual or family has chosen to arrange or oversee services and/or outcomes from the Personal Plan. This might include when services are being delivered by a family member, Personal Support Workers privately hired, Special Recreation Association programs, private day programs, or professionals/therapists who do not accept Medicaid. If you need assistance in completing the form, you can hire a Self-Direction Assistant to help you. When an individual or family has chosen agency based services only (i.e. Community Day Access, agency based Personal Support Workers), it is not necessary to complete this form.
    • Contain all the outcomes from the Personal Plan that you have agreed to work on or arrange.
    • Contain any of the following services that you will arrange: PSWs that you hire directly, Behavior Analyst, Counseling, Psychotherapy, Speech Therapy, Physical Therapy, Occupational Therapy, Nursing and Non-Medical Transportation. If you are going request Adaptive Equipment, Home or Vehicle Modifications or Assistive Technology, these must also be included.
    • All Implementation Strategies must be updated at least every year. They can be updated more often if your needs or desires change.  This Implementation Strategy does not replace the Home Based Support Service Agreement or Service Authorization. The Employer of Record must keep the completed Strategy on hand and make it available to the Independent Service Coordination (ISC) agency and Division of Developmental Disability staff as requested. If you have hired a SDA, they may also need a copy.  The Employer of Record must also ensure that all services and supports are provided and/or billed according to your HBS Service Agreements, Service Authorizations and Implementation Strategy.

    D. Employer of Record Implementation Strategy

    The Employer of Record Implementation Strategy form [IL462-1240] and instructions [IL462-1241]are available on the DHS website at this address: http://www.dhs.state.il.us/onenetlibrary/12/documents/Forms/IL462-1240.pdf and at http://www.dhs.state.il.us/onenetlibrary/12/documents/Forms/IL462-1241.pdf


    E. Home-Based Support Services Service Agreement

    You can access an electronic copy of the Home-Based Support Services (HBS) Service Agreement form [IL462-2029] by clicking on this link http://www.dhs.state.il.us/onenetlibrary/12/documents/Forms/IL462-2029.pdf