Your Signature Mail this signed form to HFS 458SP-4 R-11-07 Date Pay-In Spenddown Unit P. O. Box 19161 Springfield IL 62794 IL 478-1712. Illinois Department of Human Services PAY-IN SPENDDOWN ENROLLMENT FORM name address Date of Notice Case ID RIN You can get a medical card if you meet your monthly spenddown amount. There are three ways to meet your spenddown You can use medical bills and receipts. You can pay-in the amount of your spenddown* You can use some medical bills and receipts and pay-in the rest. Please read the enclosed Fact Sheet for more information* If you sign up to pay your spenddown we will send you a statement each month telling you how much to pay. Then you choose whether to send the statement back with your payment or take medical bills and receipts to your Human Services caseworker at the local office. Never send bills or receipts to the Pay-In Spenddown Unit. If you want to be able to pay-in to meet your spenddown answer the following questions. Then sign this for....
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How to fill out the Hfs 458sp 4 Form online
Completing the Hfs 458sp 4 Form online is an important step for individuals looking to manage their medical spenddown. This guide will walk you through the necessary sections and fields of the form to ensure a smooth filing process.
Follow the steps to successfully complete your form.
- Press the ‘Get Form’ button to obtain the form and access it in your preferred online editor.
- Begin by entering the date of notice, case ID, and RIN (Resident Identification Number) at the top of the form. These details are crucial for your application processing.
- Read through the explanation of ways to meet your monthly spenddown amount, as this section provides important options for completing the process.
- Indicate whether you have a child younger than 18 or a spouse living with you who also has a medical spenddown case by selecting 'Yes' or 'No.' If you select 'Yes', provide their name and case number in the designated areas.
- Make sure to state your intent to enroll for Pay-In Spenddown by signing your name at the bottom of the form. This confirms your understanding that you will receive monthly statements regarding your spenddown amount.
- Finally, indicate the date of your signature and mail the completed form to the specified address provided for the Pay-In Spenddown Unit.
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