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Outside of Cook County: If you live in a nursing facility outside of Cook County and are interested in speaking to someone about the possibility of living in the community, or if you know someone who lives in a nursing facility outside of Cook County who wants to learn more about living in the community and the support services that may be available there, please fill out and submit this form. Someone from one of the state, community, or healthcare agencies that work with those wishing to learn more about returning to the community will contact you to discuss your Medicaid eligibility and the assessment process. This referral form is only a first step. By submitting this form, you agree to submit your information to the Illinois Department of Healthcare and Family Services. That Department will forward your Referral Form to the agency that will discuss the possibility of a move from the nursing facility to the community with you or with the person that you referred.

In Cook County: If this referral is for someone currently living in a nursing facility in Cook County, do not complete the referral form below. Instead, please click on the following link and make the referral on the Colbert Referral System: https://webapps.illinois.gov/AGE/ColbertReferrals/ Once you fill out and submit the Referral Form on the Colbert Referral System, staff members working with Cook County/Colbert referrals will be in contact with you or with the person you referred.

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: