Home Care Provider Forms
| Application Forms |
What is the Home Care Program?
The Home Care program is intended to help families care for children who are technology dependent and require intensive skilled nursing care in their own home rather than in a hospital or skilled nursing home. The Division of Specialized Care for Children (DSCC) operates this waiver program on behalf of the Illinois Department of Healthcare and Family Services (HFS).
Who does the Home Care Program help?
Any Illinois child from birth to age 21 who is in need of long term intensive and highly technical medical care in order to be safely cared for at home, who would otherwise require treatment in a hospital or skilled nursing facility, and whose cost of care would be the responsibility of HFS.
What eligibility requirements must be met?
- The family must be willing and able to care for the child in their home.
- It must be possible to safely care for the child in the family's home.
- The child must be at risk of hospitalization or placement in a skilled nursing facility if home care services are not provided.
- The cost to HFS must be less than it would cost the state if the child were cared for in a hospital or skilled nursing facility.
What services can be provided to help my child live at home?
When needed by your child and approved in advance by the Illinois Department of Healthcare and Family Services (HFS), the following services can be provided:
- All Medical services available under the Illinois Medicaid program
- Shift Nursing care in the home, provided by registered nurses, licensed practical nurses and certified home health aides from an approved nursing agency. The number of hours provided per week are determined by the child's medical needs and prescribed by the child's physician.
- Medical equipment and supplies prescribed by the child's physician.
- Minor home modifications needed to provide access, accommodate needed medical equipment, or to assure the child's safety in the home.
- Medical Daycare which provides skilled nursing care as an alternative to in-home nursing care.
When will I know if my child is eligible?
Once the family has completed and returned the DSCC application materials, the DSCC case manager works with the family to gather the medical, home, and community information needed for HFS to determine program eligibility. This information is submitted to HFS on behalf of the family and is called a waiver application. The waiver application contains a detailed description of the child's medical condition and needs as described by the child's doctor. It also includes a plan which contains medical, environmental, educational, social, and cost information necessary for safely providing the child's care in the family's home.
Although the waiver application can usually be completed and submitted to HFS within a few weeks, it may take much longer if the child's needs change, are unusually complex, or if needed medical recommendations and cost quotations are not provided.
After a waiver application has been completed, it is reviewed with the family and then submitted to HFS. HFS will either approve or deny the application as submitted. If the application is denied, HFS will tell the family and DSCC the reason. The family can then either appeal HFS's decision or work with DSCC and their child's doctor to develop a plan which corrects the reason for denial.
What must I do after the home care plan is approved?
Once the application is approved, DSCC will help the family implement the plan. The DSCC case manager will arrange for any needed home modification, delivery of equipment and supplies, and notify the nursing agency chosen by the family. As time goes on, the case manager will meet with the family at regular intervals to ensure the plan is working, to discuss the family's satisfaction with services, and to review the family's needs. The child's plan will be reviewed, updated, and submitted to HFS for continued approval.
How do I apply?
Print the following application forms and mail them to the DSCC office in your area. You can locate the office in your area from our website.
You can fill-in and print completed forms from our web site, print blank
forms and complete them manually, or contact a DSCC Regional Office to
receive them by regular mail. Instructions
are available to explain how to complete pdf forms on-line. The Adobe
Reader, available free from the Adobe
web site, is needed to view and print these PDF files.
Note: Adobe Reader does not allow you to save completed forms to disk;
the ability to save completed forms is available commercially with the
Adobe Acrobat 3.0 (or later) product suite.
| General Application | Solicitud de Asistencia |
Or you can call your nearest DSCC office and request application forms. You will be asked to provide financial and health care information about your child and family. These forms are needed to begin the waiver application process.
More questions?
Our Families page has a listing of frequently asked questions (FAQs) which may be helpful.
Home Care Provider Forms Online
- Price Estimate for Medical
Equipment & Supplies (53.33)
Home Care Providers must complete this form annually, and whenever major changes in the child's equipment & supplies occur. The estimated cost of prescribed equipment and supplies must be submitted to ensure the child's medical plan of care remains cost effective. Providers can electronically complete this form and submit it, via fax, to the regional office coordinating the child's care. Or, the form can printed and completed manually.
- Home Nursing Services Billing Form
Nursing Agencies can fill-in and print completed forms from our web site, print blank forms and complete them manually, or contact the DSCC Call Center toll-free at 877-791-5170 to receive them by regular mail. The Home Nursing Services Billing Form (55.12) is available in 2 formats:
Microsoft Word and PDF (Portable Document Format).
- Nursing Supervisory Summary Form
The Nursing Supervisory Summary Form (55.08), or a similar form containing the same information, is required from the nursing agencies every 60 days. This information is provided to the Department of Healthcare and Family Services. It is available in 2 formats:
Microsoft Word and PDF (Portable Document Format).
Instructions are
available to explain how to complete PDF forms on-line. The Adobe
Acrobat Reader, available free from the Adobe web
site, is needed to view and print PDF files.
Note: Acrobat Reader does not allow you to save completed forms to disk; the
ability to save completed forms is available commercially with the Adobe Acrobat
3.0 (or later) product suite.
