Department of Healthcare and Family Services

Additional Financial Information for Long Term Care Applicants - 3654

Application for Hardship Waiver of a Penalty Period - 2378WA

Approved Representative Form - IL 444-2998

Authorization to Disclose Health Information - HFS 3806

Consent To Release Confidential Information - HFS 3692

Direct Payment to Attorney - CFS 1800-D

Illinois Denial of Parentage - HFS 3416D

Income Withholding for Support - HFS 3683

lllinois Voluntary Acknowledgment of Paternity - HFS 3416B

Mail-in Application for Medical Benefits - 2378H

Recission of Illinois Voluntary Acknowledgement of Paternity or Denial of Parentage - HFS 3416E

Request For A Certified Copy Of The Voluntary Acknowledgment Of Paternity and-or Denial of Paternity - HFS 3416H

Statement of Hardship - Waiver of Pentalty Period - HFS 2379WA

Supportive Living Program Notice of Appeal - 3734