Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: REVISED REQUEST FOR PARTICIPANT MO HEALTHNET REIMBURSEMENT (IM-64) FORM AND INSTRUCTIONS
FORM REVISION #17
The Request for Participant MO HealthNet Reimbursement (IM-64) and the instructions for that form have been revised and updated.
The form was updated to provide additional clarification to the participant about when this form can be used and who should use it. This form is to be used only for MO HealthNet participants who were authorized for retroactive coverage due to an incorrect agency action. MO HealthNet Division reimbursement can only be allowed for participants who cannot have their expenses reimbursed by the medical provider. Provider reimbursement must be requested first.
The form was also updated to utilize current terminology, such as Family Support Division, staff, and participant.
The instructions were revised to reflect the changes made on the form and current processes.
- Replace any outdated versions of this form immediately.
- Refer to Email IM-#03 dated January 13, 2020 for more information.
- Review this memorandum with appropriate staff.