Department of Social Services
Family Support Division
PO Box 2320
Jefferson City, Missouri
TO: ALL FAMILY SUPPORT OFFICES
FROM: KIM EVANS, DIRECTOR
SUBJECT: FEBRUARY 2025 – 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 01/2025, unless otherwise stated.
New and Revised Forms available in the public and internal forms manuals:
| Form Number | Form Name | New or Revision: |
| IM-1MAC | Addendum to MO HealthNet Application: Request for Optional Cash Benefits | Revision to add information for SNC facility base rate, add Veterans information, update rights and responsibilities to match other MHN forms, and format form for digital processing. |
| IM-1MAC (Spanish) | Complemento de la Solicitud de MO HealthNet: Solicitud de Beneficios Optionales en Dinero en Efectivo | Spanish revision of IM-1MAC. |
| IM-29PROV | MO HealthNet Spend Down Provider | New form to allow medical providers to verify qualified medical expenses to meet spend down. Creation date 11/2024. |
| IM-29SDP | MO HealthNet Spend Down Participant | New form to allow participants to provide proof of medical expenses and identify which months to apply the expenses. Creation date 11/2024. |
New and Revised Forms available only to FSD staff in the internal forms manual:
| Form Number | Form Name | New or Revision: |
| PE-1SSL | Application for Presumptive Eligibility | Updated DSS logo and added Veterans information. |
| PE-2 Worksheet | Qualified Entity Presumptive Eligibility Determination Worksheet | Updated DSS logo. |
| PE-3 | MO HealthNet Presumptive Eligibility Authorization | Updated DSS logo. |
| PE-3PW | MO HealthNet TEMP/SMHB Authorization | Updated DSS logo. |
New and Revised Online Forms
| Form Name | New or Revision: |
| MO HealthNet Spend Down Participant | New form to allow participants to provide proof of medical expenses and identify which months to apply the expenses. Links to the form have been added to mydss.mo.gov webpages. Creation date 11/2024. |
| MO HealthNet Spend Down Provider | New form to allow medical providers to verify qualified medical expenses to meet spend down. Links to the form have been added to mydss.mo.gov webpages. Creation date 11/2024. |
Obsolete forms should no longer be used by FSD staff. These forms are no longer in use with current FSD processes. Staff should work with participants and community partners to ensure that the most current forms are being used. The following forms are obsolete:
| Form Number | Form Name |
| MO 886-4501 | MO HealthNet Spend Down Provider |
Some forms and documents require only small revisions and older versions of documents may be accepted as valid, if the information provided on the form is correct. FSD may accept documents that have been obsoleted if the information provided is current and necessary eligibility determinations.
Note: Program applications and documents used to release information are exceptions. These forms must be the current revision, except during the transition period allowed after a new revision is posted.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Begin using revised forms immediately.
- Share with community partners.
KE/cj