Form HFS2538B "Illinois Department on Aging (Idoa) Notification" - Illinois

What Is Form HFS2538B?

This is a legal form that was released by the Illinois Department of Healthcare and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2010;
  • The latest edition provided by the Illinois Department of Healthcare and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HFS2538B by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form HFS2538B "Illinois Department on Aging (Idoa) Notification" - Illinois

Download PDF

Fill PDF online

Rate (4.5 / 5) 22 votes
State of Illinois
Department of Healthcare and Family Services
Illinois Department on Aging (IDoA) Notification
TO:
DATE:
FROM: (CCU Stamp)
RE: NAME:
CARE COORDINATION UNIT
ADDRESS:
CONTACT PERSON
PHONE NUMBER
CASE ID:
The FCRC must send the CCU copies of Form 267
(Note: Enter Social Security Number for new applicant only).
and 360L for applicant receiving DoA Community
Care Program services. See WAG 20-28-01.
CASE LOAD NUMBER (if available):
This is to notify the FCRC that the person named above receives services from the Department on Aging (DoA) Community Care
Program (CCP).
1.
STATUS OF MEDICAID ELIGIBILITY (CHECK ONE)
The person named above has completed an application for medical benefits. Form 2378H is attached.
The person named above has an active medical case.
2.
STATUS OF COMMUNITY CARE PROGRAM (CCP) SERVICES
Person is receiving CCP services. Effective
/
/
. The monthly costs of services are $
.
Apply the costs of services towards the person's spenddown obligation.
3.
CHANGE OF INFORMATION (CHECK AS APPROPRIATE)
Death of client Date of death:
/
/
CCP services denied/terminated effective
/
/
Spouse receiving CCP services effective
/
/
Spouse entered nursing facility or supportive living facility on
/
/
/
/
Death of spouse Date of death:
Note: Determine if case is eligible for spousal diversion. See PM15-06-02-d.
The CCU will notify DHS/FCRC of any changes in services and /or monthly cost.
Print Form
HFS 2538B (R-11-10)
State of Illinois
Department of Healthcare and Family Services
Illinois Department on Aging (IDoA) Notification
TO:
DATE:
FROM: (CCU Stamp)
RE: NAME:
CARE COORDINATION UNIT
ADDRESS:
CONTACT PERSON
PHONE NUMBER
CASE ID:
The FCRC must send the CCU copies of Form 267
(Note: Enter Social Security Number for new applicant only).
and 360L for applicant receiving DoA Community
Care Program services. See WAG 20-28-01.
CASE LOAD NUMBER (if available):
This is to notify the FCRC that the person named above receives services from the Department on Aging (DoA) Community Care
Program (CCP).
1.
STATUS OF MEDICAID ELIGIBILITY (CHECK ONE)
The person named above has completed an application for medical benefits. Form 2378H is attached.
The person named above has an active medical case.
2.
STATUS OF COMMUNITY CARE PROGRAM (CCP) SERVICES
Person is receiving CCP services. Effective
/
/
. The monthly costs of services are $
.
Apply the costs of services towards the person's spenddown obligation.
3.
CHANGE OF INFORMATION (CHECK AS APPROPRIATE)
Death of client Date of death:
/
/
CCP services denied/terminated effective
/
/
Spouse receiving CCP services effective
/
/
Spouse entered nursing facility or supportive living facility on
/
/
/
/
Death of spouse Date of death:
Note: Determine if case is eligible for spousal diversion. See PM15-06-02-d.
The CCU will notify DHS/FCRC of any changes in services and /or monthly cost.
Print Form
HFS 2538B (R-11-10)