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If you are interested in learning more about the Money Follows the Person: Pathways to Community Living program for yourself or for another individual, please fill out this form and someone from one of the participating state agencies will contact you. Eligibility for and participation in the program will be determined based on Medicaid and program eligibility and/or after an initial face-to-face meeting. This referral form is only a first step in that process. By submitting this form, you agree to submit this information to the Illinois Department of Healthcare and Family Services (HFS) for use in determining eligibility for the Money Follows the Person: Pathways to Community Living Program.

Who is this referral for?

*  

 
Information about the person being referred
First Name: *  
Last Name: *  
Middle Initial:
Gender: *  
Birth Date: *  
SSN: *  
County: *  
What type of setting does the referred currently reside in? *  
 
 

Please identify if the referral has any of the following:

 

Please check all that apply:

 

Length of Institutional Stay: *
Comments: