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