Display - Describes the relationship of the guardian to the client. The provider must obtain a copy of the legal guardianship documents to verify that guardianship is official, except for parent of minor child.
01 - Delete guardian(s) 02 - Parent of minor child (0-17) 03 -Limited of Person 04 - Limited of Estate 05 - Plenary of Person 06 - Plenary of Estate
NOTE: To delete ALL previous DHS accepted guardian information, report ''01" in Guardian Type on the first guardian.
Mandatory - Complete name and address of the guardian or responsible person.
First Name: The complete first name Middle Initial (MI): The middle initial Last Name: The complete last name
NOTE: If the person listed is not the parent of a minor child or a court appointed guardian, the provider must have in the client's file a current signed release of information to authorize release of this information.
Mandatory - The complete address of the guardian or responsible person.
Address: Street or box number City: City State: Post Office abbreviation for State Zip Code/Suffix: The five position postal zip code plus the four position suffix, if known.
Illinois Department of Human ServicesJB Pritzker, Governor · Dulce M. Quintero, Secretary
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