Get Dhs Form Il 444 2636

Filling out the Dhs Form Il 444 2636 online is a crucial step in securing medical assistance for a newborn. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the online editor.
2. Enter the 'Case Name' for the child in the designated area, ensuring that the last name, first name, and middle name are properly filled out.
3. Provide the 'Case Number' in the appropriate field to help identify the application.
4. Fill in the 'Name of Hospital' and its 'Address' including street, city, state, and zip code to indicate where the birth took place.
5. Input the 'Baby’s Full Name' including last, first, and middle names in the corresponding fields.
6. Select the 'Date of Birth' for the newborn and indicate the sex of the baby by selecting one of the options provided.
7. If applicable, provide the 'Date of Child's Adoption' or 'Date of Death' as appropriate.
8. List the names of any birth siblings in the case of a multiple birth.
9. Complete the 'Mother’s Full Name' section, including maiden name, last name, first name, and middle name.
10. Enter the mother's 'Social Security Number' and 'Birthdate' in the designated fields.
11. Provide the 'Mother's Recipient Number' to link the medical assistance to the correct recipient.
12. Fill in the 'Mother's Phone Number' and complete the 'Mother's Address' with street, city, state, and zip.
13. Complete the 'Father's Full Name' section including last name, first name, and middle name.
14. Input the father's 'Social Security Number' and 'Birthdate' as required.
15. Enter the 'Father's Address' in the relevant fields, ensuring complete details are provided.
16. Provide the name of the 'Hospital Contact Person' to ensure follow-up communication.
17. Obtain the 'Authorized Signature of Hospital Staff' along with the date for form validity.
18. Finally, include the 'Hospital Contact's Phone Number' to facilitate any necessary communication.
19. Once all sections are completed, you may save changes, download, print, or share the form as needed.

Complete your Dhs Form Il 444 2636 online to ensure timely medical assistance for your newborn.