Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: APPLICATION FOR MO HEALTHNET FOR THE AGED, BLIND, AND DISABLED (IM-1MA) REVISION
FORM REVISION # IM-1MA
DISCUSSION: The purpose of this memorandum is to introduce changes made to the IM-1MA Application for MO HealthNet (Medicaid).
The IM-1MA has been revised to include the following changes:
- Addition of the FSD.Documents@dss.mo.gov email address which may be used by participants for submitting the IM-1MA and other documents,
- A new fax number 573-526-9400 has been added where participants may submit the IM-1MA and other documents,
- A space to list preferred first name,
- An option for language preference,
- The date of marriage,
- The question; “Are you or your spouse currently serving or have you ever served in the Military?” has been added to obtain more detailed information on military service,
- The question; “Were you in foster care at age 18 or older?” has been added,
- The word “Cash” was added to the BP/SAB instructions in Section 8 to indicate if applying for BP or SAB Cash, complete this section; and
- The Rights and Responsibilities section was updated to add this statement: “I/We authorize the Director of the Family Support Division or his/her appointee to investigate and verify these circumstances and statements through any means authorized by law, including accessing public and private databases”.
The revised is available in the IM-1MA is available in the IM Forms Manual
- Review this memorandum with appropriate staff.
- Destroy all previous paper versions of the IM-1MA and immediately begin using the 08/20 version.