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Health Financial Systems
MEMORIAL HOSPITAL CARBONDALE
In Lieu of Form CMS255210
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim FORM APPROVED
payments
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What is is it realhttpswwwillinoisgovhfs?
It is the official website for the Illinois Department of Healthcare and Family Services.
Who is required to file is it realhttpswwwillinoisgovhfs?
Individuals or families who are applying for or receiving medical assistance benefits from the state of Illinois.
How to fill out is it realhttpswwwillinoisgovhfs?
You can fill out the forms online on the Illinois Department of Healthcare and Family Services website.
What is the purpose of is it realhttpswwwillinoisgovhfs?
The purpose is to determine eligibility for medical assistance benefits and to ensure proper administration of healthcare programs.
What information must be reported on is it realhttpswwwillinoisgovhfs?
Personal information, income, household size, medical expenses, and other related details.
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