2378m 2025

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The document is a mail-in application form for the State of Illinois, specifically for the payment of Medicare premiums, deductibles, and coinsurance. It provides detailed instructions on how to complete the application, including sections for personal information, health insurance details, assets, and income. The form emphasizes that it is not an application for medical assistance or other benefits like cash assistance or food stamps. Additionally, it includes information about other benefit programs available in Illinois and contact details for assistance.

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Versions	Form popularity	Fillable & printable
2010	4.9 Satisfied (55 Votes)

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