Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: REGINALD E. McELHANNON, ACTING DIRECTOR
SUBJECT: ADDING AUTOMATIC WITHDRAWAL AUTHORIZATION FORMS TO THE IM FORMS MANUAL
FORMS #26
CHIP AUTOMATIC WITHDRAWAL AUTHORIZATION
SPEND DOWN AUTOMATIC WITHDRAWAL
TICKET TO WORK AUTOMATIC WITHDRAWAL
DISCUSSION:
Automatic withdrawal forms were added to the IM Forms Manual. These forms are to be used for participants to start, change, or cancel automatic withdrawal authorizations for programs that require participant payments.
There has been no change in policy or to the forms for the automatic withdrawal authorizations.
For the Ticket to Work Health Assurance Program(TWHA): Automatic Withdrawal Authorization (Start, Change, or Cancel) for Ticket to Work Health Assurance
For the MO HealthNet for Aged, Blind and Disabled Spend Down Program: Automatic Withdrawal Authorization (Start, Change, or Cancel) for Spend Down Pay-In
For the MO HealthNet Children’s Health Insurance Program (CHIP) Premiums: Automatic Withdrawal Authorization (Start, Change, or Cancel) for MO HealthNet for Kids Insurance Premium Payments
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
RM/cj