Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: REVISION TO AUTOMATIC WITHDRAWAL AUTHORIZATION FORMS FOR MO HEALTHNET (MHN) PROGRAMS
FORM REVISION #
2575-055
2575-056
2575-057
DISCUSSION:
MO HealthNet Division (MHD) has revised the Automatic Withdrawal Authorization forms to update contact information and change the form numbers. Participants must use the revised forms to start, change, or cancel an automatic withdrawal from their bank account to pay MHN Children’s Health Insurance Programs (CHIP) premiums, MHN Ticket to Work premiums, or MHN Spend Down pay-in.
The forms are located in the public forms manual and the internal forms manual. The forms all have an August 2023 revision date.
| Form Number | Form Name |
| 2575-055 | MO HealthNet for Kids Insurance Premium Payments Automatic Withdrawal Authorization |
| 2575-056 | Spend Down Pay-In Automatic Withdrawal Authorization |
| 2575-057 | Ticket to Work Health Assurance Withdrawal Authorization |
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Share with community partners.
KE/cj