Department of Healthcare and Family Services

State of Illinois

Department of Healthcare and Family Services

REQUEST FOR FAMILYCARE BACKDATE (1 PERSON)

Date of Notice: Rep #

______Date of Application:

______Coverage Start Date:

______FC #

If you have unpaid bills from medical care you got before the coverage start date, FamilyCare may pay those bills if you qualify and the premium for each requested backdated month is paid first. If you want this coverage, complete this form and send it with your payment to the address below.

Mark the box for each backdate month requested. For each month you mark, enter $15 in Premium Due. Add up the cost for all of the months you marked and enter it in Total Premium Due.

______Month/YearPremium Due

Name of Adult______$______

______$______

______$______

______$______

______$______

Total Premium Due$______

Once we accept your payment and give you coverage, we cannot reassign your payment to a different month. However, you may request any of the additional months listed above if you pay the premium due for those months.

I understand that I am requesting FamilyCare backdate for the above person. Eligible medical services that the above person got, or are scheduled to get, before the start date of the FamilyCare Premium coverage, will be paid by FamilyCare if my request is approved.

______

Signature Date

Make your check payable to:FamilyCare Premium Plan

Please return this form with your payment to: HFS Fiscal Operations

P.O. Box 19121

Springfield, IL 62794-9121

You will be notified in writing of the approval or denial of this request. If you have questions about FamilyCare Backdate you may call toll-free 1-877-805-5312 (TTY: 1-877-204-1012), and ask for

______at extension ______.

HFS 243FC1 (N-06-09)Page 1 of 1

State of Illinois

Department of Healthcare and Family Services

REQUEST FOR FAMILYCARE BACKDATE (1 PERSON)

CREDIT CARD PAYMENTS

I authorize the FamilyCare Program / Bureau of Fiscal Operations to charge my credit card for $ ______as payment in full, in part of the outstanding balance or in advance of my FamilyCare Premium Plan.

PAYMENT INFORMATION (VISA OR MASTERCARD ONLY):

______/ ______/ ____ / ____

Credit Card Number Expiration DateSignature of Cardholder

______

Print name as it appears on cardDaytime Phone Number

To charge your FamilyCare Premium to your Credit Card, visit our E-Pay web site at and follow the on-line instructions or complete the authorization above and return the remittance form in the enclosed envelope to:

FamilyCare / Fiscal Operations

PO Box 19121

Springfield, Illinois 62794-9121

To make Credit Card payments by phone, call toll-free 1-877-828-2375. Have your Credit Card Number available when you call.

If You Have a Question:

If you have questions about this notice, or if you need information about your monthly premium, medical coverage or outstanding balance, call FamilyCare toll-free at 1-800-226-1768 (TTY: 1-800-204-1012). Also call this number to report if you or your spouse are now covered by private or employer-sponsored health insurance, or if you do not want to continue to receive FamilyCare.