IM-88 INTERNAL USE ONLY FORMS REMOVED FROM PUBLIC DEPARTMENT OF SOCIAL SERVICES (DSS) FORMS MANUAL AND MOVED TO THE INCOME MAINTENANCE (IM) FORMS MANUAL

Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri

TO:  ALL FAMILY SUPPORT OFFICES

FROM:  KIM EVANS, DIRECTOR

SUBJECT:  INTERNAL USE ONLY FORMS REMOVED FROM PUBLIC DEPARTMENT OF SOCIAL SERVICES (DSS) FORMS MANUAL AND MOVED TO THE INCOME MAINTENANCE (IM) FORMS MANUAL

 

DISCUSSION:

The DSS Manuals Forms Manual (public site) is intended to be used primarily by the public. The purpose is to assist participants and community partners who help participants with applying for and maintaining assistance from the Family Support Division (FSD).

The DSS Manuals Forms Manual (public site) has been updated to remove forms that are for internal use only. This includes many forms that staff complete and send to participants, as well as forms that are for field processing only and should not be accessible to participants.

The forms listed below are now available to staff only in the FSD Intranet Forms Manual (internal site).

 

Internal Use Only forms removed from the DSS Manuals Forms Manual:

BCC-1

BCCT Temporary Medicaid Authorization

CARS-3

Demand Letter for Overissuance

CARS-3

Out State Demand Letter (OTSTAT)

CARS-3-AE

Agency Error

CARS-3-IHE

Inadvertent Household Error (SPV-N)

CARS-3-IHE-H

Inadvertent Household Error Suspected Program Violation (SPV-Y)

CTYINFO

County Information Template (IM Forms)

FA-351

Child Care Provider Health and Safety Information

FA-352

Child Care Invoicing And Payment Information

FA-402

Letter for FA-402’s Returned After 90 Days

FA-700

Confidentiality Agreement

FA-701

FAMIS User Request

FA-702

Request for Access to FAMIS Information

FA-703

Access or Revocation of Profile to a FAMIS User Granted by Central Security Administrator

FSD/DBH

Coversheet

FSD/WIU

Tracking Sheet

IM-115

Request for Food Stamp Household Report

IM-14

Request for Interpretation of Policy

IM-145 OTH

Change Report Form

IM-16

Communication Transmittal

IM-16 Log

Child Support TA Sanction Request

IM-204

Returned Check Register

IM-206

Check Transmittal

IM-210 MHN

Report of MHN Quality Control Review

IM-29

MAGI

IM-29

Medicaid Eligibility Authorization

IM-29 OPE

Out-of-Pocket Expenses

IM-29 SPDN

Notification of Spend Down Coverage

IM-30A

MA Spend Down Worksheet

IM-30B

Surplus Computation Worksheet

IM-31

Appointment Letter

IM-311Q

QC Referral For Contact/Sanction

IM-31A

Request for Information

IM-31A

Request for Information Electronic

IM-31A

Request for Information – Spanish

IM-31A SHMB

Request for Information Show Me Healthy Babies

IM-31M

Notification of Missed Interview

IM-31Q

Notice Of Contact Requested

IM-31SPDN

Spend Down Notification

IM-32DIV

Temporary Assistance Diversion Approval Notice

IM-32MAGI

Approval Notice

IM-32MAWD

Notice of Case Action

IM-32SMHB

Action Notice – SMHB

IM-32SPDN

Notice of Approval for Medical Assistance Spend Down

IM-33

Notice of Case Action

IM-33A

Notice of Temporary Assistance/Food Stamp Case Action

IM-33MAGI

MAGI Notice of Case Action

IM-33MAGI

MAGI Notice of Case Action – Spanish

IM-33MHF

MO HealthNet for Families Notice of Action

IM-33TMH-R

Transitional MO HealthNet Quarterly Report

IM-360A

Extension or Closing Summary

IM-363

Notice of Temporary Assistance Extension for Hardship Action

IM-365

EMCIA Cover Sheet

IM-39

Request For Employment Security Information – Outside State Of Missouri

IM-39A

Request For Public Assistance Information – Outside The State Of Missouri

IM-41TA

TANF Months Used

IM-54

Referral for Services

IM-54A

Home and Community Based Services Referral/Assessment

IM-58

Transitional MO HealthNet Suspension Notice

IM-61

Social Information Summary

IM-62

Notice of Eligibility for Nursing Facility/Other Vendor

IM-62 PEME

Notice Of Post Eligibility Medical Expense Reduction In Surplus

IM-62 PEME-NFA

PEME Facility Notification – Approval

IM-62 PEME-NFD

PEME Facility Notification – Denial

IM-63 HWD

MO HealthNet Undue Hardship Waiver Decision

IM-63 HWN

MO HealthNet Undue Hardship Waiver Letter

IM-63 HWR

MO HealthNet Undue Hardship Waiver Request

IM-66 MAN

Medical Appointment Notification

IM-66 MAR

Medical Appointment Notification – Authorized Representative

IM-66 MRN

Medical Appointment Reschedule Notification

IM-66 MRR

Medical Appointment Reschedule Notification – Authorized Representative

IM-6EBT

Authorization for Release of Information

IM-76

Social Security Referral Request

IM-80

Adverse Action Notice

IM-80PRE

Pre-Closing Notice

IM-80SPDN

Non-spend down to spend down Adverse Action Notice

IM-80TMH

Adverse Action Notice

IM-82A

Notice of Vendor Termination

IM-89

Agency Representative Food Stamp Hearing Control Log

IM-90

Withdrawal of Request for Hearing

IM-90A

Agency Action Rescinded

IM-90B

Agency Action Withdrawn Participant Notification

IM-94A

Family Child Care Provider Notice of Registration (Appr/Rej)

IM-94B

Parental Notice of Family Child Care Provider Registration (Appr/Rej)

Menu

Adds Menu Items for IM Forms to MS Word

MO 580-2421

Family Care Safety Registration  – Child Care And Elder-Care Worker Registration

MRT Checklist

MRT Checklist

PE-1

SSL Application

PE-2

Worksheet

PE-3

PE Auth

PE-3

TEMP SMHB

WRKRINFO

Worker Information Template

 

SSI/SSDI Transition Letter

 

SSI/SSDI Transition Letter – Spanish

 

Signature Request Letter

 

Internal Inspections Report/Field Office

 

IRS Notice Log

 

Research and Evaluation Request

 

Standard Visitor Log

 

DHSS Referral Letter

 

DHSS Referral Letter-Spend Down

 

Application for Other Benefits letter

 

MO HealthNet Spend Down Discussion Checklist

 

Temporary Assistance Diversion Transmittal Form

 

NECESSARY ACTION:

  • Review this memorandum with appropriate staff.
  • Update saved links.

 

KE/cj