IM-84 FORMS FOR MULTIPLE PROGRAMS TRANSLATED INTO SPANISH

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  FORMS FOR MULTIPLE PROGRAMS TRANSLATED INTO SPANISH

DISCUSSION:

The following forms have been translated into Spanish and the Spanish versions have been added to the Forms Manual:

FORM NUMBER

FORM NAME

IM-1MA

Medicaid Application/Eligibility Statement

IM-1MAC

Addendum to MO HealthNet Application:  Request for Optional Cash Benefit

IM-1U MAGI

MAGI Annual Review

IM-1 QMB-SLMB

Application for Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries

IM-6ARR

IM Authorized Representative Revocation

IM-6NF

Nursing Facility Authorization Form

IM-12

Employment Information Request

IM-12A

New Employee Information Request

IM-31A SMHB

Request for Information-SMHB

IM-32SMHB

Action Notice SMHB

IM-33

Notice of Case Action

IM-33MAGI

MAGI Notice of Case Action

IM-33MHF

MO HealthNet for Families Notice of Action

IM-55A

Transitional Medicaid Quarterly Report-1st Quarter

IM-55B

Transitional Medicaid Quarterly Report-2nd Quarter

IM-55C

Transitional Medicaid Quarterly Report-3rd Quarter

IM-58

Transitional MO HealthNet Suspension Notice

650-2616

(HIPAA) Authorization for Disclosure of Consumer Medical/Health Information

IM-63HWN

MO HealthNet Undue Hardship Waiver Letter

IM-64HWR

MO HealthNet Undue Hardship Waiver Request

IM-78

Declaration of Assessment of Assets

IM-80

Adverse Action Notice

IM-80PRE

Pre-Closing Notice

IM-80 TMH

Adverse Action Notice

IM-87

Application for State Hearing

IM-90

Withdrawal of Request for Hearing

IM-90A

Agency Action Rescinded

IM-90B

Agency Action Withdrawn Participant Notification

IM-99

Burial Fund Resource Designation (IM-99)

 

REQUEST TO WITHDRAW OR CLOSE

CS-201

Referral/Information for Child Support Services

 

SSI/SSDI TRANSITION LETTER

 

SIGNATURE REQUEST LETTER

 

Utilize these forms as needed for participants who indicate a preference for written material in Spanish.

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.

 

RM/ams/ers