Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: JULY 2023 – QUARTERLY FORMS UPDATE
DISCUSSION:
Income Maintenance forms and documents are reviewed and revised quarterly and as necessary. New forms and documents are created as required or requested.
All new and revised IM forms show a revision date of 7/2023, unless otherwise stated. Revised IM forms with older revisions dates are now obsolete. Family Support Division (FSD) will accept obsolete forms until 9/30/2023.
New and Revised Forms available in the public and internal forms manuals:
| Form Number | Form Name | New or Revision: |
| HIPP-1 | Application for Health Insurance Premium Payment (HIPP) Program | MO HealthNet Division (MHD) updated and revised the application. This form has a revision date of 2/2023. |
| HIPP-1 | Solicitud para el Programa de Pago de Primas de Securos Medicos *(HIPP) | MHD updated and revised the application. This form has a revision date of 2/2023. |
| HIPP-A | Application for Health Insurance Premium Payment (HIPP) Program – Care Coordinator Version | MHD updated and revised the application. This form has a revision date of 2/2023. |
| HIPP-A | Solicitud para el Programa de Pago de Primas de Securos Medicos *(HIPP) – Coordinador de Cuidados | MHD updated and revised the application. This form has a revision date of 2/2023. |
| IM-2SR | Signature Request | Revision to update terminology from review to renewal. |
| IM-6NF | Authorization for Release of Medical/Health Information to Nursing Facilities, In-Home Nursing Care Providers, and Other Providers of Medical Services | Revision to use official name, add electronic signature attestation, remove one year expiration date, and update formatting to improve readability. |
| IM-114 | Voluntary Repayment Authorization Form | Revision to update terminology, contact information, and processes. |
| MO 231-0167 | Missouri Voter Registration Application | Secretary of State revised to add optional political party affiliation and remove rural voters field. This form has a revision date of 5/2023. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision: |
| IM-33HCB | Notice of Case Action for Home and Community Based Services Waiver | New action notice for cases requesting or receiving Home and Community Based Services (HCB) Waiver benefits. |
| IM-54A | Home and Community Based Services Referral | Revision to correct a broken hyperlink. |
Revised forms sent to participants by FAMIS or MEDES eligibility systems:
| Form Number | Form Name | Revision: |
| HIPP-1 | Application for Health Insurance Premium Payment (HIPP) Program | Updated in MEDES to match revisions made by MHD. Released in MEDES 5/30/23. |
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Begin using revised forms immediately.
- Discard and recycle blank obsolete forms.
- Share with community partners.
KE/cj