Table of Contents
The HFS 3654 form is an essential document for individuals seeking long-term care assistance in Illinois. This form, issued by the Illinois Department of Healthcare and Family Services, gathers crucial financial information to determine eligibility for medical assistance. It requires applicants to provide detailed answers about their financial situation, including any income tax returns filed in the past five years and previous living arrangements. The form also prompts individuals to disclose how they have been managing their nursing care expenses prior to applying for assistance. Additionally, it inquires about any assistance received in handling financial matters, whether from family members or professionals. Questions regarding marital status, insurance policies related to nursing home care, and any recent inheritances are also included, ensuring a comprehensive overview of the applicant's financial landscape. Completing this form accurately is vital, as it directly impacts the evaluation process for receiving necessary medical support.
Example - Hfs 3654 Illinois Form
Document Breakdown
| Fact Name | Details |
|---|---|
| Purpose | The HFS 3654 form is used to gather additional financial information from applicants seeking long-term care medical assistance in Illinois. |
| Filing Requirements | Applicants must answer all questions completely, provide necessary documentation, and sign the form before submission. |
| Governing Law | This form is governed by the Illinois Public Aid Code, specifically related to medical assistance eligibility for long-term care. |
| Submission Details | It can be submitted by the applicant or on their behalf by a hospital or long-term care facility, along with the required admission and discharge dates. |
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