Illinois Department of Healthcare and Family ServicesIllinois Department of Human Services

03/21/14

Information Memo

Summary:

  • Revised forms - Many HFS forms were revised to be consistent with policy changes implemented in response to state and federal laws including the 2012 SMART Act and the Deficit Reduction Act of 2005;
  • New forms - A number of new HFS forms were introduced to carry out new and revised policy and to simplify existing procedure;
  • The new forms and revised forms (listed below) are available at HFS InfoNet.

Revised HFS Forms:

  • HFS 458LTC - Notice of Decision on Application for Medical Assistance - MANG Long Term Care/Supportive Living Facility
  • HFS 458M (E/S) - Notice of Decision on Application for Payment of Medical Premiums, Deductibles and Co-Insurance
  • HFS 458SP-3 - Notice of Determination of Spenddown Met/Unmet - MANG Long Term Care
  • HFS 1229A - Long Term Care/Supportive Living Facility Redetermination Report Form
  • HFS 1442 - Health Insurance Report
  • HFS 2378H - Mail-In Application for Medical Benefits
  • HFS 2434C (E/S) - Notice of Change - MANG Long Term Care
  • HFS 2500 - Nursing Home/Supportive Living Facility Calculation
  • HFS 2538A (E/S) - Special Information for Persons Receiving/Applying for Community Care Program Services Through the Department on Aging
  • HFS 3190 (E/S) - Determination of Resource Allowance
  • HFS 3191 (E/S) - Nursing Home Services and Information for Couples [Brochure]
  • HFS 3489 - Transfer of Resources Worksheet
  • HFS 3654 (E/S) - Additional Financial Information for Long Term Care Applicants
  • HFS 3654A - Long Term Care - Asset Discovery Investigation (LTC-ADI) Referral Form
  • HFS 3703 - Exempt Irrevocable Trust Referral

New HFS Forms:

  • HFS 267LTC - Instructions to Client (Long Term Care)
  • HFS 458WA - Notice of Decision on Application for Hardship Waiver
  • HFS 2378WA - Application for Hardship Waiver of A Penalty Period
  • HFS 2378WA1 - Application for Hardship Waiver Due to Home Value
  • HFS 2379WA - Hardship Affidavit of Deprivation

Obsolete HFS Forms:

  • HFS 3189 (E/S) - Request for Information
  • HFS 3192 - Determination of Asset Allowance

[signed copy on file]

Michelle R. B. Saddler Secretary,

Illinois Department of Human Services

Julie Hamos

Director, Illinois Department of Healthcare and Family Services