Document 6506729

PAY-IN SPENDDOWN STATEMENT
Date of Notice
(Customer Name & Address)
Case No.:
RIN:
Your monthly spenddown amount is _____. You can decide how to meet your spenddown.
Pay now - If you will need to fill a prescription, see your doctor or dentist, or get any other
medical care soon, it might be best for you to pay your spenddown now. As soon as we confirm
your payment, we will send you a medical card for the month you choose.
Do not pay – If you do not think you will need medical care in the next month, it might be better
for you to wait and meet your spenddown with medical bills and receipts.
If you want to pay your spenddown, fill out
the bottom of this page and send it with your
payment in the enclosed envelope to:
Spenddown Payment/Fiscal Operations
P. O. Box 19141
Springfield, IL 62794
Did you get form 458SP-1C from us showing that you have an amount AVAILABLE that you
have not used yet to meet spenddown? If so, you can subtract that amount from the payment you
are sending us.
If you want to find out how much you need to pay to get your medical card or you have other
questions, call the Pay-In Spenddown Unit at 1-800-226-0768. If you use a TTY, call 1-866675-8440. The call is free.
Apply my payment of --$_______ to __________ (1st month)
Apply my payment of --$_______ to __________ (2nd month)
Apply my payment of --$_______ to __________ (3rd month)
Total Amount Sent
$___________
You should tell us the month you are paying for. If you don’t tell us, we will apply the amount
you pay toward the first month listed above.
Do not send a personal check. Personal checks will be returned to you. We prefer that you pay
with a money order, cashier’s check, credit or debit card for the total amount you fill in above.
Make your money order or cashier’s check payable to HFS.
If you want to pay with your VISA or MasterCard, complete the section below:
Name on VISA/MC: ____________________________________________________________
Cardholder’s Signature: __________________________________________________________
Credit/Debit Card# ________________________________________Exp Date _____/___ /____
HFS 458SP-5 (R-11-07)
IL 478-1712