Ill. Admin. Code tit. 59, pt. 117, subpt. C, app B, ILLUSTRATION E
Illinois Department of Human Services
ELIGIBLITY DETERMINATION - PRIMARY EXAMINERS - CHILDREN AND ADULTS WITH SEVERE AND MULTIPLE IMPAIRMENTS
Name of applicant: ______________________________________________________
Date of examination: _____________________________________________________
I verify that I am aboard eligible/certified psychiatrist
licensed clinical psychologist
licensed physician
and that the above-named individual was evaluated personally by me.
I verify that I have found the person to meet the eligibility criteria for determination as Children and Adults with a Severe and Multiple Impairments.
I verify that I have found the person does not meet the eligibility criteria for determination as Children and Adults with a Severe and Multiple Impairments.
I have attached my evaluation and copies of any other evaluations used by me in making this determination.
Name (type or print) ________________________
Signature ________________________________
Address _________________________________
________________________________________
________________________________________
License no. _______________________________
Return in self-addressed, stamped envelope or send to:
Department of Human Services
Home-Based Support Services Program
Room 405 Stratton Building
Springfield IL 62765
Ill. Admin. Code tit. 59, pt. 117, subpt. C, app B, ILLUSTRATION E