Blank Hfs 3654 Illinois PDF Form

What is the purpose of the HFS 3654 form?

The HFS 3654 form is designed to gather additional financial information from individuals applying for long-term care assistance in Illinois. It helps the Department of Healthcare and Family Services assess eligibility for medical assistance based on the applicant's financial situation. By providing detailed financial data, applicants can ensure that their needs are accurately evaluated and that they receive the appropriate level of support.

Who needs to fill out the HFS 3654 form?

This form must be completed by anyone applying for long-term care services in Illinois. Whether you are currently residing in a nursing home or planning to enter one, this form is essential for demonstrating your financial status. It is also necessary for those who have received assistance from a hospital or long-term care facility, as they may need to provide additional information about their admission and discharge dates.

What information is required on the HFS 3654 form?

The form requires various personal and financial details. Applicants must provide their name, address, and contact information, as well as details about their living situation over the past few years. Additionally, it asks about income sources, financial assistance, insurance policies, and any inheritances received. Completing this form accurately is crucial, as it directly impacts the evaluation process for medical assistance.

What should I do if I have not filed a tax return in the last 60 months?

If you have not filed a state or federal income tax return in the last 60 months, you should indicate "No" on the form. However, it’s important to note that you may still be required to provide other financial documentation to support your application. This could include bank statements, proof of income, or other relevant financial records. Always ensure that you provide as much information as possible to facilitate the review process.

Is it necessary to provide information about my spouse?

Yes, if you are married or have a recent spouse, you need to provide their information on the form. This includes their name, address, phone number, and Social Security Number, if applicable. If your spouse is deceased or you are divorced, you will need to include relevant details such as the date and place of death or divorce. This information helps assess your financial situation accurately, as it may impact your eligibility for assistance.

What happens if I inherit money or property while my application is pending?

If you inherit money, property, or other assets within 60 months of submitting your application, you must disclose this information on the HFS 3654 form. The form asks for details about the inheritance, including its value and the date received. Inheritances can affect your eligibility for assistance, so it’s essential to report them promptly and accurately to avoid potential issues with your application.

1. Incomplete Information: Failing to answer all questions can lead to delays or denials. Each section must be filled out completely.

2. Incorrect Dates: Providing inaccurate admission or discharge dates can create confusion. Ensure that all dates are correct and clearly stated.

3. Missing Signatures: Not signing the document is a common oversight. A signature is required to validate the application.

4. Omitting Tax Returns: If applicable, failing to provide copies of tax returns for the last three years can hinder the application process.

5. Neglecting Previous Addresses: Not listing the last two residences can result in incomplete information. This is crucial for the assessment of eligibility.

6. Ignoring Financial Assistance: If someone has been helping with financial matters, this information must be disclosed. Omitting it can affect the evaluation.

7. Marital Status Errors: Providing incorrect marital status or failing to include necessary details about a spouse can complicate the application.

8. Insurance Policy Details: Not including information about insurance policies that cover nursing home care can lead to misunderstandings regarding financial resources.

9. Inheritances Not Reported: Failing to disclose any inheritances received within the last 60 months can lead to issues with eligibility for assistance.

The HFS 3654 form is an important document for individuals applying for long-term care assistance in Illinois. Along with this form, several other documents may be required to support your application. Each of these documents serves a specific purpose and helps ensure that your application is processed smoothly. Below is a list of commonly used forms and documents that may accompany the HFS 3654.

• Income Tax Returns: Copies of your state and federal income tax returns for the past three years may be needed. These documents provide a clear picture of your financial situation.
• Proof of Residency: Documentation showing your previous addresses, such as utility bills or lease agreements, may be necessary to confirm your living history before applying for long-term care.
• Power of Attorney (POA) Documents: If someone is assisting you with financial matters, a copy of the POA document is important. This verifies that the person has the authority to act on your behalf.
• Divorce Decree: If you are divorced, including a copy of your divorce decree is essential. This helps clarify your marital status and any obligations related to your former spouse.
• Insurance Policy Information: If you have a long-term care insurance policy, details such as the policy number and the insurance company’s name will be required to assess your coverage.
• Inheritance Documentation: If you have received an inheritance within the last 60 months, documents that outline the value and source of the inheritance will be necessary.
• Financial Planner or Attorney Statements: If you consulted with a financial planner or attorney regarding your long-term care needs, statements or letters from these professionals can provide valuable context for your application.
• Proof of Marital Status: Documents that confirm your current marital status, such as a marriage certificate or death certificate, may be needed to complete your application accurately.

Gathering these documents ahead of time can help streamline the application process for long-term care assistance. Ensuring that you have all necessary paperwork ready will make it easier to provide accurate information and meet any deadlines set by the state. If you have any questions about these documents, consider reaching out to a professional for guidance.

The HFS 3654 Illinois form is designed to gather additional financial information for long-term care applicants. Several other documents serve similar purposes in various contexts. Here’s a list of those documents and how they relate to the HFS 3654 form:

• Medicaid Application Form: This form collects comprehensive financial and personal information to determine eligibility for Medicaid, similar to the HFS 3654's focus on financial details for long-term care applicants.
• Long-Term Care Insurance Application: This document assesses an applicant's financial situation to determine coverage eligibility, much like the HFS 3654 evaluates financial resources for nursing home care.
• Social Security Administration (SSA) Benefits Application: This application requires personal and financial information to assess eligibility for benefits, paralleling the HFS 3654's aim to gather financial data.
• Financial Aid Application for Nursing Home Residents: This form requests detailed financial information to determine aid eligibility, mirroring the financial inquiries made in the HFS 3654.
• Veterans Affairs (VA) Aid and Attendance Application: This document collects financial details to assess eligibility for additional VA benefits, similar to how the HFS 3654 evaluates financial resources for care.
• Estate Planning Questionnaire: This questionnaire gathers financial and personal information to help plan for asset distribution, akin to the HFS 3654's focus on financial matters related to long-term care.
• Power of Attorney Document: This document outlines who can manage financial affairs for someone else, often requiring similar financial disclosures, which aligns with the HFS 3654's inquiry about financial management assistance.

When filling out the HFS 3654 form for Illinois, it is essential to ensure accuracy and completeness. Here are six important do's and don'ts to keep in mind:

• Do read all instructions carefully before starting the form.
• Do answer all questions completely and accurately.
• Do provide copies of required documents, such as tax returns, if applicable.
• Do sign the document before submission.
• Don't leave any questions unanswered; this may delay processing.
• Don't submit the form without reviewing it for errors or omissions.

Misconceptions about the HFS 3654 Illinois form can lead to confusion and errors in the application process. Below are eight common misconceptions along with clarifications.

• The form is only for nursing home residents. The HFS 3654 form is applicable to anyone applying for medical assistance related to long-term care, not just those currently in a nursing home.
• Only financial information is required. While financial information is a significant part of the form, applicants must also provide personal details, such as marital status and previous residences.
• Submission is optional. Completing and submitting the HFS 3654 form is a requirement for those seeking medical assistance for long-term care. Failure to submit the form can delay or deny assistance.
• All questions must be answered if they do not apply. If a question does not apply to the applicant, it is acceptable to indicate that by writing "N/A" or leaving it blank, rather than forcing an answer.
• Only recent tax returns are needed. Applicants must provide copies of their tax returns for the last three years, not just the most recent one.
• Help from family or friends is not necessary to report. If someone assists the applicant with financial matters, this must be disclosed on the form, regardless of the nature of the assistance.
• Inheritance must be reported only if it is large. Any inheritance received within the last 60 months, regardless of the amount, must be reported on the form.
• Divorce decrees are not necessary. If the applicant has been divorced, a copy of the divorce decree must be submitted with the form, unless it is unavailable, in which case specific details must be provided.

Understanding these misconceptions can help ensure that the application process is completed accurately and efficiently.

Filling out the HFS 3654 form is an important step for individuals applying for long-term care assistance in Illinois. Here are some key takeaways to keep in mind:

• Complete All Sections: Ensure that every question on the form is answered fully and accurately. Incomplete forms may delay the processing of your application.
• Provide Tax Returns: If you have filed a state or federal income tax return in the last five years, you must include copies of those returns with your application.
• List Previous Residences: If you are currently in a nursing home, you need to provide addresses of the last two places you lived before your admission.
• Financial Assistance Disclosure: If someone is assisting you with your finances, you must disclose their name and relationship to you. This includes help with bank accounts, insurance, and investments.
• Consultation History: If you have discussed your need for nursing care with a financial planner or attorney in the last five years, be prepared to provide their contact information.
• Insurance Policies: If you have a long-term care insurance policy, you must provide details about the policy and the recipient of the payments.
• Inheritance Information: Report any inheritance received within the last five years, including details about the deceased and the value of the inheritance.

By keeping these points in mind, you can ensure a smoother application process for long-term care assistance in Illinois.