Making the Connection | Illinois

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Home Medical

Medical Questionnaire

Finding medical coverage is complex.  It is similar to stitching together a complicated quilt.  Due to the complexity of finding medical care, we provide two ways to screen for eligibility.  One way is to answer a number of questions, another is to look at our Patchwork Quilt.

Please check all that apply and hit next.

1. There are children in my home who I support and who are under 18
2. I or someone in my home is currently pregnant
3. I or someone in my is aged 65 and older, blind or disabled
4. I or someone in my home is a veteran or dependent of a veteran
5. I am a woman between the ages of 19 and 64
6. None of the above
Files
 IL444-0400 Receipt.pdf[IDHS Receipt of Application]403 Kb
 IL444-0400S Receipt Spanish.pdf[IDHS Receipt of Application (Espanol)]426 Kb
 

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