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Request for medical benefits for another family member(s) - dhs state il 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your name as it appears on the MediPlan or All Kids/FamilyCare ID Card, along with your address and phone number.
- Fill in the case number from your MediPlan or All Kids/FamilyCare ID Card. If known, include the CSID on the MediPlan card.
- List the names of the individuals you are requesting benefits for, including their sex, birth date, and Social Security Number.
- Indicate your relationship to each person and whether they are an Alaska Native or American Indian. For those under 19, provide parental names.
- Answer questions regarding previous medical care received in the last three months and any current insurance coverage details.
- Complete income-related sections if applicable, providing necessary documentation such as pay stubs or proof of other income sources.
- Finally, review all entered information for accuracy before signing and dating the form at the bottom.
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Related links
If you want to add another family member to your case, fill out a Request for Medical Benefits for Another Family Member HFS 243C form (pdf) and send it toRead more
You may have to re-apply for coverage. You may also need to re-apply for yourself or other family members. To re-apply, visit abe.illinois.gov/access/ orRead more
This document has been reviewed in accordance with U.S. Environmental Protection Agency policy and approved for publication and distribution.Read more