Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: INTRODUCING NEW MEDICAL REVIEW TEAM PACKET (IM-61MRT), UPDATING DISABILITY DETERMINATION FORMS, AND OBSOLETING THE MO HEALTHNET AGED, BLIND, AND DISABLED APPLICATION APPENDICES
FORM REVISION #
IM-61MRT
IM-61B
IM-61D
DISCUSSION:
Introducing IM-61MRT
A new forms packet has been created for MO HealthNet for the Aged, Blind, and Disabled (MHABD) disability determinations. The Medical Review Team Packet to Determine Disability (IM-61MRT) contains many of the forms that are necessary for Family Support Division staff to request medical records, schedule evaluations, and make a disability determination during the Medical Review Team (MRT) process.
The IM-61MRT packet includes:
- Disability History (IM-61B)
- Work History (IM-61C)
- Provider History (IM-61D)
- Authorization for Disclosure of Consumer Medical/Health Information (MO 650-2616)
Updating Disability Determination Forms
Two of the forms used during the MRT process were updated for clarity and to improve the disability determination process.
The IM-61B has been renamed Disability History (previously Disability Questionnaire) for consistency with other forms used for disability determinations.
The IM-61D has been renamed Provider History (previously Hospitals, Medical Facilities and Physicians Seen within the Past Year). The form requests information for any medical providers the participant has seen in the last five (5) years. This change is to gather a more thorough medical history for the MRT process.
Obsolete MHABD Application Appendices
The MHABD application appendices are now obsolete. Any unused forms in offices should be destroyed.
The forms that were included in the appendices can be accessed individually in the Department of Social Services (DSS) Manuals Forms Manual:
- Disability History (IM-61B)
- Work History (IM-61C)
- Provider History (IM-61D)
- Authorization for Disclosure of Consumer Medical/Health Information (MO 650-2616)
- Declaration and Assessment of Assets (IM-78)
- Appointing an Authorized Representative (IM-6AR)
- Authorization for Release of Medical/Health Information Nursing facilities, In-Home Nursing Care Providers, and Other Providers of Medical Services (IM-6NF)
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
KE/cj