Form 26-74910 Medicaid Redetermination Medical Renewal - Illinois

Form 26-74910 is a Illinois Department of Healthcare and Family Services form also known as the "Medicaid Redetermination Medical Renewal". The latest edition of the form was released in February 1, 2014 and is available for digital filing.

Download a PDF version of the Form 26-74910 down below or find it on Illinois Department of Healthcare and Family Services Forms website.

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State of Illinois
Department of Healthcare and Family Services
Department of Human Services
Illinois Medicaid Redetermination
00067
HH_NAME (NMG_NULL_ENGLISH)
ADDRESS LINE1
991010101
IMR7AZE
ADDRESS LINE2
00-IMR2BR1E-3
NMG - EN
CITY ST
February 12, 2014
Case ID: 066066010011Y
Dear HH_NAME (NMG_NULL_ENGLISH),
It is time to renew your medical coverage!
It’s time for renewal, also known as “redetermination” or “re-de.”
Here’s what to do:
1. Answer all questions on this form.
2. Make sure all the information is correct. If any information is wrong, cross it out and
write in the correct information.
3. Sign this form at the bottom of page 4.
4. Attach proof documents for income and expenses and other proofs we ask for.
5. Send your signed form and all proofs by February 25, 2014.
Send your form and proofs to us one of these ways:
® Fax your form and proofs to 1-866-661-7025
® Mail your form and proofs in the envelope that we sent you
® E-mail your form and proofs to www.medredes.hfs.illinois.gov
Your medical benefits may end if you do not send your proofs by February 25, 2014.
Call us at 1-855-458-4945 (TTY: 1-855-694-5458) if you cannot send everything on time
or if you have questions. We may be able to help you get the proofs you need.
Thank you,
Illinois Medicaid Redetermination
Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!
Monday to Friday from 7 a.m. to 7:30 p.m. and Saturday from 8 a.m. to 1 p.m.
E-mail us at www.medredes.hfs.illinois.gov or send a fax to 1-866-661-7025.
Tenemos información en español. ¡Servicio de intérpretes gratis!
Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
01-03-7-01
State of Illinois
Department of Healthcare and Family Services
Department of Human Services
Illinois Medicaid Redetermination
00067
HH_NAME (NMG_NULL_ENGLISH)
ADDRESS LINE1
991010101
IMR7AZE
ADDRESS LINE2
00-IMR2BR1E-3
NMG - EN
CITY ST
February 12, 2014
Case ID: 066066010011Y
Dear HH_NAME (NMG_NULL_ENGLISH),
It is time to renew your medical coverage!
It’s time for renewal, also known as “redetermination” or “re-de.”
Here’s what to do:
1. Answer all questions on this form.
2. Make sure all the information is correct. If any information is wrong, cross it out and
write in the correct information.
3. Sign this form at the bottom of page 4.
4. Attach proof documents for income and expenses and other proofs we ask for.
5. Send your signed form and all proofs by February 25, 2014.
Send your form and proofs to us one of these ways:
® Fax your form and proofs to 1-866-661-7025
® Mail your form and proofs in the envelope that we sent you
® E-mail your form and proofs to www.medredes.hfs.illinois.gov
Your medical benefits may end if you do not send your proofs by February 25, 2014.
Call us at 1-855-458-4945 (TTY: 1-855-694-5458) if you cannot send everything on time
or if you have questions. We may be able to help you get the proofs you need.
Thank you,
Illinois Medicaid Redetermination
Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!
Monday to Friday from 7 a.m. to 7:30 p.m. and Saturday from 8 a.m. to 1 p.m.
E-mail us at www.medredes.hfs.illinois.gov or send a fax to 1-866-661-7025.
Tenemos información en español. ¡Servicio de intérpretes gratis!
Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
01-03-7-01
State of Illinois
Department of Healthcare and Family Services
Department of Human Services
991010101
Illinois Medicaid Redetermination
Case ID: 066066010011Y
Medical Renewal Form
1. Do these people still live with you?
£
£
MEMBER NAME1
01/01/1999
Yes
No
2. Tell us about anyone else who lives with you:
Relationship to you
Name
Date of birth
(for example: spouse, child,
First, Middle, Last, Suffix (Jr., Sr., II or III)
)
(month/day/year
parent)
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
Name:
Date of birth:
Relationship:
£
£
3.
Did you or anyone living with you get new health insurance in the last year?
Yes
No
If yes, name of insurance plan:_________________________________ Policy number: _____________________________
Who is covered by this health insurance? ____________________________________________________________________
Name of insurance plan:_______________________________________ Policy number: _____________________________
Who is covered by this health insurance? ____________________________________________________________________
Page 1
Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!
Monday to Friday from 7 a.m. to 7:30 p.m. and Saturday from 8 a.m. to 1 p.m.
E-mail us at www.medredes.hfs.illinois.gov or send a fax to 1-866-661-7025.
Tenemos información en español. ¡Servicio de intérpretes gratis!
Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
02-03-7
4. Do you and everyone living with you still get this income from these sources?
£
£
Salary, wages, and tips for everyone ......................
Total per month: $ 1111.99
Is this correct?
Yes
No
(total before taxes are taken out)
£
£
Self-employment income for everyone ...................
Total per month: $ 2222.99
Is this correct?
Yes
No
(profit once business expenses are paid)
£
£
Unemployment for everyone................................... Total per month: $ 3333.99
Is this correct?
Yes
No
£
£
Social Security for everyone ................................... Total per month: $ 4444.99
Is this correct?
Yes
No
£
£
Supplemental Security Income (SSI) for everyone... Total per month: $ 9999.99
Is this correct?
Yes
No
£
£
Workers' Compensation benefits for everyone........ Total per month: $ 1199.99
Is this correct?
Yes
No
£
£
Veterans benefits for everyone................................ Total per month: $ 2299.99
Is this correct?
Yes
No
£
£
Pension or retirement income for everyone............. Total per month: $ 5555.99
Is this correct?
Yes
No
£
£
Spousal support or child support
Total per month: $ 6666.99
Is this correct?
Yes
No
received by everyone..............................................
£
£
Rental fees or royalties for everyone........................Total per month: $ 7777.99
Is this correct?
Yes
No
£
£
Other income for everyone .....................................Total per month: $ 3399.99
Is this correct?
Yes
No
Æ
If you checked no for any income, write the correct amount in the next section.
5. Do you or anyone living with you get other income? Check all that apply.
£
How much?
How often?
Salary, wages, and tips
£
How much?
How often?
Self-employment
£
How much?
How often?
Unemployment
£
How much?
How often?
Social Security
£
Supplemental Security Income (SSI)
How much?
How often?
£
How much?
How often?
Workers’ Compensation benefits
£
Veterans benefits
How much?
How often?
£
How much?
How often?
Pension or retirement income
£
How much?
How often?
Spousal support or child support
£
How much?
How often?
Inheritance or trust fund
£
How much?
How often?
Rental fess or royalties
£
Other:__________________________
How much?
How often?
Æ
Attach proof of the amount for any income received in the last 30 days.
Page 2
State of Illinois
Department of Healthcare and Family Services
Department of Human Services
991010101
Illinois Medicaid Redetermination
Case ID: 066066010011Y
6. Do you or anyone living with you pay any of these expenses? Check all that apply.
£
How much?
How often?
Spousal suppor or child support
£
How much?
How often?
Child care expenses
£
How much?
How often?
Employment expenses
£
How much?
How often?
Other:______________________________
Æ
Attach proof of all expenses paid in the last 30 days.
7. Do you or anyone living with you still own these resources (assets) with these values?
£
£
Cash and bank accounts................................... Total $ 1111.00
Is this correct?
Yes
No
£
£
Life insurance (cash value)................................. Total $ 2222.00
Is this correct?
Yes
No
£
£
Burial fund or trust fund..................................... Total $ 3333.00
Is this correct?
Yes
No
£
£
Car, truck or motor vehicle................................ Total $ 8888.00
Is this correct?
Yes
No
£
£
Other property or land....................................... Total $ 5555.00
Is this correct?
Yes
No
£
£
Mutual funds, stocks, bonds............................. Total $ 4444.00
Is this correct?
Yes
No
£
£
401(k), IRA or Keough accounts........................ Total $ 7777.00
Is this correct?
Yes
No
£
£
Other resources................................................ Total $ 6666.00
Is this correct?
Yes
No
Æ
If you checked no for any resources, write the correct values in the next section.
8. Do you or anyone living with you own other resources (assets)? Check all that apply.
£
Cash and bank accounts
What is the value?
$ ___________________________________
£
Life insurance (cash value)
What is the value?
$ ___________________________________
£
Burial fund or trust fund
What is the value?
$ ___________________________________
£
Car, truck or motor vehicle
What is the value?
$ ___________________________________
£
Other property or land
What is the value?
$ ___________________________________
£
What is the value?
$ ___________________________________
Mutual fund, stocks, bonds
£
What is the value?
$ ___________________________________
401(k), IRA or Keough accounts
£
What is the value?
$ ___________________________________
Other:__________________________
Æ
Attach proof showing who owns these resources and the current value.
You do not need to attach proof of the value of your vehicle or your home.
Page 3
Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!
Monday to Friday from 7 a.m. to 7:30 p.m. and Saturday from 8 a.m. to 1 p.m.
E-mail us at www.medredes.hfs.illinois.gov or send a fax to 1-866-661-7025.
Tenemos información en español. ¡Servicio de intérpretes gratis!
Redetermination Notice (Non-MAGI)
02/14 - NMG - EN - 1
Llame al 1-855-458-4945.
20440212.999990000100 - 991010101
26 - 74910
03-03-7
9. Read and sign below:
¡
I understand that officials in charge of my health benefits may check all information on this form.
¡
I understand they may check my information electronically. If they ask for my help checking
information, I must cooperate.
¡
I understand that anyone who knowingly lies or provides untrue information, or arranges
for someone to knowingly lie or provide untrue information, or intentionally misuses the
health benefits card issued by the State of Illinois, may be committing a crime which can be
prosecuted or punished under federal law, state law, or both.
¡
If the Illinois Department of Healthcare and Family Services pays medical bills for me, the State
of Illinois may collect my medical support payments instead of me.
¡
I am signing this form under the penalty of perjury. That means the information I have provided
on this renewal form is true to the best of my knowledge, and I may be punished under law if I
provide false or untrue information.
________________________________________________
______________________________
Your signature
Today's date
10. Remember! Make sure you answered all questions and signed the form.
Æ
Send this form to us with all proofs by February 25, 2014.
Page 4

Download Form 26-74910 Medicaid Redetermination Medical Renewal - Illinois

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