Illinois Request for an Individuals Health Information

State:
Multi-State
Control #:
US-3577
Format:
Word; 
Rich Text
Instant download

Description

This form is used by an individual to request access to his or her protected health information. The individual's rights regarding this access are also acknowledged by the individual.

How to fill out Request For An Individuals Health Information?

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FAQ

You can submit your SNAP Recertification application by mail, from your home by using the internet ( ), by fax, or in person at your local department of social services. After you submit your application, you must be interviewed.

Apply for Benefits Portal (ABE.Illinois.gov) To apply for healthcare, food and cash assistance benefits, click the blue "Apply for Benefits" button. You will need to set up an account, log in and fill out the online application. Supporting documents can also be uploaded after the application is signed and submitted.

Use one of the 3 easy ways below: 1. Complete the electronic version of this form online in ABE Manage My Case at abe.illinois.gov; or 2. Fill out, sign, and send us this form and all verifications we ask for. You may send the form by mail or fax.

You can also check your status by phone by calling the IDHS helpline at 1-800-843-6154. When prompted, from the available list of options, choose "food stamps" then "case status." You will need your Social Security number and your case number in order to progress through the system and check your status.

Applications can be submitted at ABE.Illinois.gov or by calling the ABE hotline at 1-800-843-6154. Please be advised - customers applying for SNAP or cash benefits may receive a telephone call from DHS Staff using a 217 area code.

You may also write the Department of Human Services (IDHS) at Department of Human Services, Bureau of Civil Affairs, 401 South Clinton St., 6th Floor, Chicago, Illinois, 60607 or call the IDHS Helpline Number at 1-800-843-6154 or 866-324-5553 TTY/Nextalk or 711 Relay.

To get more information on applying for Medicaid, please contact the Health Benefits Hotline at 1-800-843-6154. TTY users can call 855-889-4326.

How to Set Up a Manage My Case:Go to abe.illinois.gov. R.Click on the green Manage My Case button. Enter your ABE User ID and Password.After logging in, select 'Link your account'When you link your case to your ABE account, you will be asked to answer a few questions to confirm your identity.05-Jun-2020

MEDICAID APPLICATION DOCUMENTSDRIVERS LICENSE, PHOTO ID CARD, OR PASSPORT.SOCIAL SECURITY CARD FOR APPLICANT, (and spouse if living)RED, WHITE AND BLUE MEDICARE CARD.HEALTH INSURANCE CARDS, PREMIUM AMOUNT STATEMENT.BIRTH CERTIFICATES FOR APPLICANT (Naturalization papers for immigrants) MARRIAGE CERTIFICATE if married.

You can renew your benefits online with an ABE account. If you'd rather renew in person, call your caseworker, local office (select Family Community Resource Center from the Office Type dropdown), or the Illinois SNAP hotline (1-800-843-6154) to find out how.

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Illinois Request for an Individuals Health Information