IM-84 FORMS FOR MULTIPLE PROGRAMS TRANSLATED INTO SPANISH

TO: ALL FAMILY SUPPORT OFFICES

FROM: KIM EVANS, DIRECTOR

SUBJECT: FORMS FOR MULTIPLE PROGRAMS TRANSLATED INTO SPANISH

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-1^st 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IM-90A	Agency Action Rescinded
IM-90B	Agency Action Withdrawn Participant Notification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.

RM/ams/ers