2378m 2026

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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Click ‘Get Form’ to open the 2378m application in the editor.
Begin by filling out the 'Personal Information' section. Enter your name, address, date of birth, and social security number. Indicate if you live in a nursing home or assisted living facility.
Next, list all individuals living with you, including their names and relationships. Ensure accuracy as this information is crucial for your application.
Proceed to the 'Health Insurance' section. Report any Medicare coverage you have and provide details about private health insurance if applicable.
In the 'Assets' section, list any property or vehicles owned by you or your spouse. Include current values and any outstanding debts on these items.
Complete the 'Income and Earnings' section by detailing all sources of income before deductions. Be thorough to ensure eligibility for benefits.
Finally, review your entries for completeness and accuracy before signing the application at the end of the form.

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