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127
![Sample "Illinois Medicaid Redetermination" - Illinois](https://data.templateroller.com/pdf_docs_html/1999/19996/1999630/sample-illinois-medicaid-redetermination-illinois.png "Sample "Illinois Medicaid Redetermination" - Illinois")
Sample "Illinois Medicaid Redetermination" - Illinois
Size: 3 MB
4 pages
This form is used by applicants every year to renew their Medicaid coverage. By filling in this form annually, applicants provide actual information about their income, which can change from year to year.
![Formulario SBE R-19 "Aplicacion Para Registro De Votantes De Illinois" - Illinois (Spanish)](https://data.templateroller.com/pdf_docs_html/1797/17976/1797658/formulario-sbe-r-19-aplicacion-para-registro-de-votantes-de-illinois-illinois-spanish.png "Formulario SBE R-19 "Aplicacion Para Registro De Votantes De Illinois" - Illinois (Spanish)")
![Form HFS26 "Report on Resident of Private Long Term Care Facility" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20169/2016945/form-hfs26-report-on-resident-of-private-long-term-care-facility-illinois.png "Form HFS26 "Report on Resident of Private Long Term Care Facility" - Illinois")
![Form HFS650 "Standardized Illinois Early Intervention Referral Form" - Illinois](https://data.templateroller.com/pdf_docs_html/2024/20246/2024680/form-hfs650-standardized-illinois-early-intervention-referral-form-illinois.png "Form HFS650 "Standardized Illinois Early Intervention Referral Form" - Illinois")
![Form HFS652 "Illinois Early Intervention Program Referral Fax Back Form" - Illinois](https://data.templateroller.com/pdf_docs_html/2024/20246/2024672/form-hfs652-illinois-early-intervention-program-referral-fax-back-form-illinois.png "Form HFS652 "Illinois Early Intervention Program Referral Fax Back Form" - Illinois")
![Form HFS724 "Screening, Assessment and Evaluation Tool Approval Request Form" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20169/2016939/form-hfs724-screening-assessment-and-evaluation-tool-approval-request-form-illinois.png "Form HFS724 "Screening, Assessment and Evaluation Tool Approval Request Form" - Illinois")
![Form HFS185 "Client/Applicant Discrimination Claim" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797630/form-hfs185-client-applicant-discrimination-claim-illinois.png "Form HFS185 "Client/Applicant Discrimination Claim" - Illinois")
![Form SDU-012 "Authorization Agreement for Automatic Deposits" - Illinois](https://data.templateroller.com/pdf_docs_html/1804/18041/1804197/form-sdu-012-authorization-agreement-automatic-deposits-illinois.png "Form SDU-012 "Authorization Agreement for Automatic Deposits" - Illinois")
![Form HFS3692 "Consent to Release Confidential Information" - Illinois](https://data.templateroller.com/pdf_docs_html/2063/20639/2063946/form-hfs3692-consent-to-release-confidential-information-illinois.png "Form HFS3692 "Consent to Release Confidential Information" - Illinois")
![Form HFS3654 "Additional Financial Information for Long Term Care Applicants" - Illinois](https://data.templateroller.com/pdf_docs_html/2024/20246/2024670/form-hfs3654-additional-financial-information-for-long-term-care-applicants-illinois.png "Form HFS3654 "Additional Financial Information for Long Term Care Applicants" - Illinois")
![Form HFS3732 "Involuntary Discharge Notice of Appeal and Request for Hearing" - Illinois](https://data.templateroller.com/pdf_docs_html/2024/20246/2024676/form-hfs3732-involuntary-discharge-notice-of-appeal-and-request-for-hearing-illinois.png "Form HFS3732 "Involuntary Discharge Notice of Appeal and Request for Hearing" - Illinois")
![Form HFS1409 "Prior Approval Request Form" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20169/2016942/form-hfs1409-prior-approval-request-form-illinois.png "Form HFS1409 "Prior Approval Request Form" - Illinois")
![Form HFS2292 "Adjustment (Nips)" - Illinois](https://data.templateroller.com/pdf_docs_html/2024/20246/2024678/form-hfs2292-adjustment-nips-illinois.png "Form HFS2292 "Adjustment (Nips)" - Illinois")
![Form HFS2211 (IL478-1020) "Laboratory/Portable X-Ray Invoice" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797642/form-hfs2211-il478-1020-laboratory-portable-x-ray-invoice-illinois.png "Form HFS2211 (IL478-1020) "Laboratory/Portable X-Ray Invoice" - Illinois")
![Form HFS2212 "Health Agency Invoice" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797633/form-hfs2212-health-agency-invoice-illinois.png "Form HFS2212 "Health Agency Invoice" - Illinois")
![Form HFS2210 (IL478-1105) "Medical Equipment / Supplies Invoice" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797653/form-hfs2210-il478-1105-medical-equipment-supplies-invoice-illinois.png "Form HFS2210 (IL478-1105) "Medical Equipment / Supplies Invoice" - Illinois")
![Form HFS3785 "Questionnaire for Negative Pressure Wound Therapy" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20169/2016938/form-hfs3785-questionnaire-for-negative-pressure-wound-therapy-illinois.png "Form HFS3785 "Questionnaire for Negative Pressure Wound Therapy" - Illinois")
![Form HFS3082 "Drug Prior Authorization Request Form" - Illinois](https://data.templateroller.com/pdf_docs_html/1801/18010/1801049/form-hfs-3082-drug-prior-authorization-request-form-illinois.png "Form HFS3082 "Drug Prior Authorization Request Form" - Illinois")
![Form HFS1662 "Primary Care Physician/Pharmacy Authorization (Non-emergency Services Only)" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797624/form-hfs1662-primary-care-physician-pharmacy-authorization-non-emergency-services-only-illinois.png "Form HFS1662 "Primary Care Physician/Pharmacy Authorization (Non-emergency Services Only)" - Illinois")
![Form HFS1432 "Long Term Care Provider Agreement Nursing Facilities and Icf/Iid (Provider Types 33 and 29)" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20166/2016632/form-hfs1432-long-term-care-provider-agreement-nursing-facilities-and-icf-iid-provider-types-33-and-29-illinois.png "Form HFS1432 "Long Term Care Provider Agreement Nursing Facilities and Icf/Iid (Provider Types 33 and 29)" - Illinois")
![Form HFS1433 "Long Term Care Provider Agreement State-Operated Facility (Provider Type 34)" - Illinois](https://data.templateroller.com/pdf_docs_html/1799/17999/1799925/form-hfs-1433-long-term-care-provider-agreement-state-operated-facility-provider-type-34-illinois.png "Form HFS1433 "Long Term Care Provider Agreement State-Operated Facility (Provider Type 34)" - Illinois")
![Form HFS1446 "Long Term Care (Snf/Icf) Provider Monthly Assessment Report" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20166/2016630/form-hfs1446-long-term-care-snf-icf-provider-monthly-assessment-report-illinois.png "Form HFS1446 "Long Term Care (Snf/Icf) Provider Monthly Assessment Report" - Illinois")
![Form HFS3304 "Important Disclosure Statement Regarding Legal Representation" - Illinois](https://data.templateroller.com/pdf_docs_html/1804/18041/1804198/form-hfs-3304-important-disclosure-statement-regarding-legal-representation-illinois.png "Form HFS3304 "Important Disclosure Statement Regarding Legal Representation" - Illinois")
![Form HFS1435 "Nursing Facility Traumatic Brain Injury (Tbi) Notification" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797660/form-hfs1435-nursing-facility-traumatic-brain-injury-tbi-notification-illinois.png "Form HFS1435 "Nursing Facility Traumatic Brain Injury (Tbi) Notification" - Illinois")
![Form HFS1156 "Long Term Care Facility Notification" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20166/2016631/form-hfs1156-long-term-care-facility-notification-illinois.png "Form HFS1156 "Long Term Care Facility Notification" - Illinois")
![Form HFS2249 "Adjustment (Hospital)" - Illinois](https://data.templateroller.com/pdf_docs_html/2016/20166/2016622/form-hfs2249-adjustment-hospital-illinois.png "Form HFS2249 "Adjustment (Hospital)" - Illinois")
![Form HFS1507 "Payment Instruction Sheet" - Illinois](https://data.templateroller.com/pdf_docs_html/1804/18042/1804200/form-hfs-1507-payment-instruction-sheet-illinois.png "Form HFS1507 "Payment Instruction Sheet" - Illinois")
![Form HFS1517 "Provider Forms Request" - Illinois](https://data.templateroller.com/pdf_docs_html/1799/17999/1799911/form-hfs-1517-provider-forms-request-illinois.png "Form HFS1517 "Provider Forms Request" - Illinois")
![Form HFS2119 (IL478-0357) "Paternity Affidavit" - Illinois](https://data.templateroller.com/pdf_docs_html/1810/18102/1810293/form-hfs-2119-form-il-478-0357-paternity-affidavit-illinois.png "Form HFS2119 (IL478-0357) "Paternity Affidavit" - Illinois")
![Form HFS3859 "Statement of Identity" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797649/form-hfs3859-statement-of-identity-illinois.png "Form HFS3859 "Statement of Identity" - Illinois")
![Form HFS2307 "Hospital, Professional School or Practitioner Owned Group Practice as Alternate Payee" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797636/form-hfs2307-hospital-professional-school-or-practitioner-owned-group-practice-as-alternate-payee-illinois.png "Form HFS2307 "Hospital, Professional School or Practitioner Owned Group Practice as Alternate Payee" - Illinois")
![Form HFS3127 "Request for Inappropriate Level of Care Payment" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797638/form-hfs3127-request-for-inappropriate-level-of-care-payment-illinois.png "Form HFS3127 "Request for Inappropriate Level of Care Payment" - Illinois")
![Form HFS1977 "Acknowledgement of Receipt of Hysterectomy Information" - Illinois](https://data.templateroller.com/pdf_docs_html/2008/20080/2008054/form-hfs1977-acknowledgement-of-receipt-of-hysterectomy-information-illinois.png "Form HFS1977 "Acknowledgement of Receipt of Hysterectomy Information" - Illinois")
![Form HFS2316 "Limited Power of Attorney" - Illinois](https://data.templateroller.com/pdf_docs_html/1796/17968/1796848/form-hfs2316-limited-power-of-attorney-illinois.png "Form HFS2316 "Limited Power of Attorney" - Illinois")
![Form HFS3725 "Payment Review Request Form (Ltc)" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797623/form-hfs3725-payment-review-request-form-ltc-illinois.png "Form HFS3725 "Payment Review Request Form (Ltc)" - Illinois")
![Form HFS3731 "Supportive Living Program Notice of Involuntary Discharge" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797654/form-hfs3731-supportive-living-program-notice-of-involuntary-discharge-illinois.png "Form HFS3731 "Supportive Living Program Notice of Involuntary Discharge" - Illinois")
![Form HFS3773 "Late Filing Affidavit" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797644/form-hfs3773-late-filing-affidavit-illinois.png "Form HFS3773 "Late Filing Affidavit" - Illinois")
![Form HFS3461 "Long Term Care Facility Third Party Liability (Tpl) Payment Transmittal" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797647/form-hfs3461-long-term-care-facility-third-party-liability-tpl-payment-transmittal-illinois.png "Form HFS3461 "Long Term Care Facility Third Party Liability (Tpl) Payment Transmittal" - Illinois")
![Form HFS2243 "Provider Enrollment Application in the Medical Assistance Program" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17975/1797554/form-hfs2243-provider-enrollment-application-in-the-medical-assistance-program-illinois.png "Form HFS2243 "Provider Enrollment Application in the Medical Assistance Program" - Illinois")
![Form HFS3905 "Hospital Bed Questionnaire" - Illinois](https://data.templateroller.com/pdf_docs_html/1797/17976/1797635/form-hfs3905-hospital-bed-questionnaire-illinois.png "Form HFS3905 "Hospital Bed Questionnaire" - Illinois")
