Get Il Dhfs Hfs 3654 2012-2025

Filling out the IL DHFS HFS 3654 form is essential for long term care applicants seeking medical assistance. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the IL DHFS HFS 3654 form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by providing the DHS case number if applicable in the designated field at the top of the form.
3. Enter your personal information: last name, middle initial, first name, street address, city, state, county, zip code, and phone number.
4. If your mailing address differs from your residential address, complete the mailing address section.
5. Answer the questions about your state or federal income tax returns from the last 60 months, ensuring that you specify which years if applicable.
6. List the two addresses where you lived prior to moving to a nursing home, or the last two places you lived if not yet in a nursing home.
7. Detail how you have been paying for nursing care before submitting the application.
8. Indicate whether someone helps you manage your financial affairs and provide their contact details if applicable.
9. Discuss any conversations about nursing home residency with relevant parties within the last 60 months, including names and contact details.
10. State your marital status and provide information about your current or most recent spouse, if applicable.
11. If you have an insurance policy that pays out for nursing home care, list the details including policy number and who receives payments.
12. Indicate if you inherited money or property within the last 60 months, providing details on the inheritance.
13. Specify whether you hold resources jointly with another person and describe these joint resources.
14. Answer questions regarding annuities purchased, resources closed or cashed in, and any transfers or loans made within the last 60 months.
15. Confirm if you owned specific resources within the last 60 months and supply necessary details.
16. Finally, read through the certification statement, sign the form, and ensure that all applicable fields are completed before submission.
17. Once completed, users can save their changes, download, print, or share the form as desired.

Complete your IL DHFS HFS 3654 form online today to ensure timely processing of your application.