Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: FORM REVISIONS TO HEALTH INSURANCE PREMIUM PAYMENT PROGRAM (HIPP) APPLICATIONS AND AUTOMATIC WITHDRAWAL FORMS
FORM REVISION #
Multiple forms have been revised in the Department of Social Services (DSS) Forms Manual to provide updated versions of forms maintained by other divisions.
Application for Health Insurance Premium Payment Program (HIPP-1) and Application for Health Insurance Premium Payment Program for HIV/AIDS (HIPP-A) forms were updated by MO HealthNet Division with a revision date of 8/2020.
Ticket to Work Health Assurance Automatic Withdrawal Authorization (MO 886-4704), Spenddown Pay-In Automatic Withdrawal Authorization (MO 886-4705), and MO HealthNet for Kids Insurance Premium Payments Automatic Withdrawal Authorization (MO 886-4706) forms were updated by the Division of Finance and Administrative Services (DFAS) with a revision date of 1/2021. These forms now have form numbers and the form numbers were added to the DSS Forms Manual.
- Review this memorandum with appropriate staff.