Forms Manual Spanish

Forms Manual Spanish

Forms Manual Spanish

Form NumberTitleinstruccionesPDFLetra grandeSobresalirLetra
123-12455Spanish Title Goes HereinstruccionesLetra grande
650-2616Authorization for Disclosure of Consumer Medical/Health Information (HIPAA) instruccionesPDFSobresalir
Affidavit of Disaster LossPDF
Audit Document Request ForminstruccionesPDF
886-4706Automatic Withdrawal Authorization – CHIP/MO HealthNet for Kids (MHK) Insurance Premium PaymentsPDF
886-4705Automatic Withdrawal Authorization – Spenddown Pay-InPDF
886-4704Automatic Withdrawal Authorization – Ticket To Work Health Assurance (TWHA)PDF
B-2 Application for Services - Rehabilitation Services for the BlindPDF
BCC-2Certification of Need for TreatmentPDF
CARS-3Demand Letter for Overissuanceinstrucciones
CARS-3-AEAgency ErrorPDF
CARS-3-IHE Inadvertent Household Error (SPV-N)PDF
CARS-3-IHE-HInadvertent Household Error Suspected Program Violation (SPV-Y)PDF
CARSRepayment Agreement PDF
Case Manager Performance Plan
Case Worker Performance Plan
CD-202Child Care Schedule Verification Request Form
CTYINFOCounty Information Template (IM Forms)
DHSS Referral Letter
DHSS Referral Letter-Spend Down
DOI-1 Referral for Investigation
FA-312 VA VendorPDF
FA-313VA Vendor LetterPDF
FA-402Letter for FA-402’s Returned After 90 Days
FA-351Child Care Provider Health and Safety Information
FA-352Child Care Invoicing And Payment InformationPDF
FA-700Confidentiality Agreement
FA-701FAMIS User Request
FA-702Request for Access to FAMIS Information
FA-703Access or Revocation of Profile to a FAMIS User Granted by Central Security Administrator
MO 580-2421 Family Care Safety Registration - Child Care And Elder-Care Worker RegistrationPDF
Flow Chart for Pregnant Women ApplicationsPDF
FSD/DBH Coversheet PDF
FSD/WIU Tracking Sheet (See IM-#101 2004/IM-#5 2008)instruccionesPDF
IM-1Application for Benefits
IM-1ADPMO HEALTHNET SOLA ADICION OPTIMIZADA - SpanishPDF
IM-1QMB-SLMBApplication for Medicare Savings for Qualified Beneficiaries or Specified Low-Income BeneficiariesPDF
IM-1SSL OngoingOngoing Coverage Signature Request for Household MembersPDF
IM-1SSL -SPSolicitud de Cobertura de Salud & Ayuda para Pagar los CostosPDF
IM-1SSL-suppSupplemental Form for Family MO HealthNet ProgramsPDFLetra
IM-1SSL-letterParticipant Supplemental Form LetterPDF
IM-1UMAGI Annual ReviewPDF
IM-2BStatement Of Parent Or Sighted SpouseinstruccionesPDF
IM-2UEligibility Recording Form
IM-4EBTEBT Information PamphletinstruccionesPDF
IM-4Food Assistance Brochure - Large PrintPDF
IM-4Information You Need About Fraud instruccionesPDF
IM-4FS/SRReporting Changes for the Food Stamp PrograminstruccionesPDF
IM-4Home and Community Based (HCB) ServicesPDF
IM-4 MAInformation about your Medical AssistanceinstruccionesPDF
IM-4 Medicare Savings Program (MSP) FlyerPDF
IM-4 MHNDIM-4 MHN Nondiscrimination NoticePDF
IM-4MO HealthNet FlyerPDF
IM-4 MLISIM-4 Multi-Language Interpreter ServicesPDF
IM-4MO HealthNet for Nursing Home Care FlyerPDF
IM-4myDSS FlyerPDF
IM-4 PRMMO HealthNet for Kids - CHIP Premium ChartPDF
IM-4 SMHBShow Me Healthy Babies FlyerPDF
IM-4SkillUP BrochurePDF
IM-4SkillUP FlyerPDF
IM-4Spend Down BrochurePDF
IM-4Supplemental Nursing Care (SNC) FlyerPDF
IM-4TATemporary Assistance BrochurePDF
IM-4Ticket to Work Health Assurance Program (TWHA)PDF
IM-4Transitional MO HealthNetPDF
IM-4Vendor Planning FlyerPDF
IM-6Authorization for Release of InformationPDF
IM-6ARIM Authorized RepresentativeinstruccionesPDFLetra grande
IM-6ARRIM Authorized Representative RevocationPDF
IM-6EBTAuthorization for Release of Informationinstrucciones
IM-6EVS Authorization for Verification formPDF
IM-6NFNursing Facility Authorization FormPDF
IM-61DLP-OPTHOphthalmologist/Optometrist Information Request - Large PrintPDF
IM-7Financial Information Request
IM-9Insurance and Prepaid Burial LetterinstruccionesPDF
IM-10School Verification Report
IM-12Employment Information Request
IM-12ANew Employee Information Request
IM-12BNew Hire Informationinstrucciones
IM-14Request for Interpretation of Policy
IM-16Communication TransmittalinstruccionesPDF
IM-16 LogChild Support TA Sanction RequestSobresalir
IM-20Agreement for Direct Deposit
IM-23Client Services PostcardinstruccionesPDF
IM-29MAGIPDF
IM-29Medicaid Eligibility Authorization
IM-29 OPEOut-of-Pocket ExpensesPDF
IM-29 PAProvider Attestation of Physician's Order of Medical NecessityPDF
IM-29 SPDNNotification of Spend Down CoveragePDF
IM-29 TEMO HealthNet Spend Down Transportation Expense Log
IM-30AMA Spend Down Worksheet
IM-30BSurplus Computation Worksheet
IM-30CExplanation of Financial Eligibility
IM-30IBCAIncome Maintenance Budget (IBCA)
IM-31Appointment Letter
IM-31ARequest for Informationinstrucciones
IM-31ARequest for Information Electronic
IM-31ARequest for Information - SpanishinstruccionesPDF
IM-31APQ MAGIPDF
IM-31A SHMBRequest for Information Show Me Healthy Babies
IM-31A MC+MC+ Request for InformationPDF
IM-31FInstructions for Making Your Food Stamp Application/Food Stamp RightsinstruccionesPDF
IM-31MNotification of Missed Interviewinstrucciones
IM-31QNotice Of Contact RequestedinstruccionesPDF
IM-31SPDNSpend Down Notification
IM-32DIVTemporary Assistance Diversion Approval Notice
IM-32MAGIApproval Notice
IM-32MAWDNotice of Case Action
IM-32MCMC+ Approval Notice (Non-premium groups)
IM-32MPWMC+ for Pregnant Women Approval Notice
IM-32PRMMC+ Approval Notice (Premium Group)
IM-32QMBNotice of ApprovalPDF
IM-32SLMBNotice of ApprovalPDF
IM-32SMHBAction Notice – SMHB
IM-32SPDNNotice of Approval for Medical Assistance Spend Down
IM-33Notice of Case ActionPDF
IM-33ANotice of Temporary Assistance/Food Stamp Case Action
IM-33MAFMAF Notice of Case Action
IM-33MAGIMAGI Notice of Case ActionPDF
IM-33MAGIMAGI Notice of Case Action - SpanishPDF
IM-33MCMC+ Notice of Denial
IM-33MCCMC+ Notice of Action
IM-33MHFMO HealthNet for Families Notice of ActionPDF
IM-33TMH-RTransitional MO HealthNet Quarterly Reportinstrucciones
IM-34Change of Status Summary
IM-35Identification Data Form
IM-36Vital Statistics Form
IM-37Insurance Form
IM-38IM-2 Recording WorksheetPDF
IM-39Request For Employment Security Information - Outside State Of MissouriinstruccionesPDF
IM-39ARequest For Public Assistance Information - Outside The State Of MissouriinstruccionesPDF
IM-41TATANF Months Used
IM-42Inter-county Transfer
IM-50AAInformation Notice - Regarding an Action on Your CasePDF
SkillUP Providers HandbookPDF
BCC-1BCCT Temporary Medicaid AuthorizationPDF
CARS-3Out State Demand Letter (OTSTAT)instruccionesLetra
CARS-8Request for Reduction of ClaiminstruccionesPDF
CS-201Referral/Information for Child Support ServicesinstruccionesPDF
FA-402MO HEALTHNET Eligibility Review InformationPDF
Family Care Safety Registry BrochurePDF
FS-1Application for Food Stamp BenefitsinstruccionesPDF
FSD-4Customer Service ForminstruccionesPDF
HIPP-1Application for Health Insurance Premium Payment (HIPP) ProgramPDF
HIPP-AApplication for Health Insurance Premium Payment (HIPP) ProgramPDF
IM-1ADPMO Healthnet Single Streamlined AdditionPDF
IM-1BCCBCCT MA ApplicatonPDF
IM-1CCChild Care ApplicationPDF
IM-1CCLPChild Care Application - Large PrintPDF
IM-1ABDSAged, Blind, & Disabled SupplementPDFLetra grande
IM-1MAGWMO HealthNet/Gateway to Better Health Application/Eligibility StatementPDF
IM-1REQApplication Request Letter
IM-1SSLApplication for Health Coverage & Help Paying CostsPDFLetra
IM-1TAApplication for Temporary Assistance Cash BenefitsPDF
IM-1TASFApplication for Temporary AssistancePDF
IM-1U90-Day LetterPDF
IM-1U MAGIAnnual ReviewPDF
IM-1U MAGIAnnual Review - SpanishPDF
IM-2Application for BenefitsPDF
IM-2Blind Pension AddendumPDF
IM-2ABlind Pension SupplementinstruccionesPDF
IM-2Mod Adult Adult Supplement - SpanishPDF
IM-2CExpenses of Producing Income - Spanish
IM-2ENotice of Requirement to Cooperate & Right to Claim Good Cause - Part 1PDF
IM-2E2nd Notice of Right to Claim Good Cause - Part 2PDF
IM-2EHExtension for HardshipinstruccionesPDF
IM-2QMB-SLMBMedicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries ReviewPDF
IM-3AReinvestigation NoticePDF
IM-3EBTImportant Information About Electronic Benefit Transfer (EBT) Transactionsinstrucciones
IM-3Temporary Assistance OrientationPDF
IM-3PRPPersonal Responsibility PlanPDF
IM-3TADRUGTemporary Assistance Drug Testing Applicant Notice
IM-4Annual Review PosterPDF
IM-4Child Care Subsidy BrochurePDF
IM-4Finding Help BrochurePDF
IM-4Finding Help Brochure - Large PrintPDF
IM-4Food Assistance BrochurePDF
IM-4Hearing RightsinstruccionesPDF
IM-4Hearing Rights - SpanishinstruccionesPDF
IM-4Health Care BrochurePDF
IM-4Health Care Brochure - SpanishPDF
IM-42ACounty Transfer Letter
IM-54Referral for Services
IM-54AHome and Community Based Services Referral/AssessmentinstruccionesPDF
IM-55ATransitional MO HealthNet - First Quarterly ReportinstruccionesPDF
IM-55BTransitional MO HealthNet - Second Quarterly Reportinstrucciones
IM-55CTransitional MO HealthNet - Third Quarterly Reportinstrucciones
IM-58Transitional MO HealthNet Suspension Noticeinstrucciones
IM-60AMedical Report Including Physician's Certification/Disability EvaluationinstruccionesPDF
FS-61SNAP (Food Stamps) Summary to Determine Fitness for WorkPDF
IM-61Social Information SummaryinstruccionesPDF
IM-61BDisability QuestionnaireinstruccionesPDF
IM-61BDisability Questionnaire (Informational)instruccionesPDF
IM-61CWork History - Past 10 YearsinstruccionesPDF
IM-61DHospitals, Medical Facilities and Physicians Seen within the Past YearinstruccionesPDF
IM-61D OPTHOphthalmologist / Optometrist Information RequestinstruccionesPDF
IM-61DLP OPTHOphthalmologist / Optometrist Information Request - Large PrintinstruccionesPDF
IM-62Notice of Eligibility for Nursing Facility/Other Vendor
IM-62 PEMENotice Of Post Eligibility Medical Expense Reduction In SurplusPDF
IM-62 PEME-NFAPEME Facility Notification - ApprovalPDF
IM-62 PEME-NFDPEME Facility Notification - DenialPDF
IM-63 PEMEPost Eligibility Medical Expense Budgeting Request
IM-63 HWDMO HealthNet Undue Hardship Waiver Decision
IM-63 HWNMO HealthNet Undue Hardship Waiver Letter
IM-63 HWRMO HealthNet Undue Hardship Waiver Request
IM-64Request for Participant MO HealthNet ReimbursementinstruccionesPDF
IM-66 MANMedical Appointment Notification
IM-66 MARMedical Appointment Notification - Authorized Representative
IM-66 MRNMedical Appointment Reschedule Notification
IM-66 MRRMedical Appointment Reschedule Notification - Authorized Representative
IM-68Visual Disability Examination ReportPDF
IM-70Good Faith Effort to Sell DeclarationPDF
IM-71Certification of Need for Psychiatric ServicesPDF
IM-72Facility Notification Information SheetPDF
IM-76Social Security Referral RequestinstruccionesPDF
IM-78Declaration and Assessment of AssetsinstruccionesPDF
IM-79Intent to Transfer Assets Agreement
IM-79ANotification of Requirement to Transfer Assets
IM-80Adverse Action NoticePDF
IM-80AWaiver of 10-day Advance NoticePDF
IM-80MCMC+ Advance Action NoticePDF
IM-80PREPre-Closing Notice
IM-80SPDNNon-spend down to spend down Adverse Action NoticePDF
IM-80TMHAdverse Action Noticeinstrucciones
IM-82ANotice of Vendor Termination
IM-87Application for State HearinginstruccionesPDF
IM-89Agency Representative Food Stamp Hearing Control LoginstruccionesPDF
IM-90Withdrawal of Request for Hearinginstrucciones
IM-90AAgency Action Rescindedinstrucciones
IM-90BAgency Action Withdrawn Participant Notificationinstrucciones
IM-94AFamily Child Care Provider Notice of Registration (Appr/Rej)
IM-94BParental Notice of Family Child Care Provider Registration (Appr/Rej)
IM-99Burial Fund Resource Designation
IM-102Food Stamp Worksheet
IM-103Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular PayrollinstruccionesPDF
IM-108Student Income Verification
IM-110Statement of Loss/Replacement RequestinstruccionesPDF
IM-112Action Taken on Your Food Stamp CaseinstruccionesPDF
IM-113Replacement Request/Affidavit for Food Stamp Benefits Lost from EBT AccountinstruccionesPDF
IM-114Voluntary Repayment Authorization FormPDF
IM-115Request for Food Stamp Household Reportinstrucciones
IM-145Change Report Form
IM-145BChange Report
IM-145 OTHChange Report Form
IM-150Suspending MO HealthNet Participants FormPDF
IM-151Requesting Inpatient CoveragePDF
IM-152Reporting Release of MO HealthNet ParticipantPDF
IM-160Advance Notice of your Administrative Disqualification HearinginstruccionesPDF
IM-161Waiver of Administrative HearinginstruccionesPDF
IM-161AWithdrawal of Waiver of Administrative Hearing/DQ Consent AgreementPDF
IM-204Returned Check Register
IM-206Check Transmittal
IM-209Case Reading Form
IM-210Report of Food Stamp Quality Control Reviewinstrucciones
IM-210 MHNReport of MHN Quality Control Review
IM-214Affidavit for Replacement CheckinstruccionesPDF
IM-215Affidavit of ForgeryPDF
IM-311Referral and TransmittalinstruccionesPDF
IM-311QQC Referral For Contact/SanctioninstruccionesPDF
IM-360AExtension or Closing SummaryPDF
IM-363Notice of Temporary Assistance Extension for Hardship ActionPDF
IM-365EMCIA Cover Sheet
IM-366Drug Conviction Exception Determination Worksheet
IM-367Current Probation and Parole/Court Compliance Drug Conviction Exception Verification
IM-368Discharged Parolee Drug Conviction Exception Verification
Application for Other Benefits letter
Internal Inspections Report/Field Officeinstrucciones
IRS Notice LoginstruccionesSobresalir
MenuAdds Menu Items for IM Forms to MS Word
MO HealthNet Spend Down Discussion ChecklistPDF
MO HealthNet Spend Down Provider FormPDF
MRT ChecklistMRT ChecklistinstruccionesPDF
PC-1Presumptive Eligibility DeterminationPDF
PC-2MO HealthNet for Kids Presumptive Eligibility DeterminationPDF
PE-1SSL ApplicationPDF
PE-2Worksheetinstrucciones
PE-3PE Auth
PE-3TEMP SMHB
Program Improvement Planinstrucciones
QIT AgreementQualified Income TrustPDF
Request to Withdraw or Close
Research and Evaluation Requestinstrucciones
Signature Request Letter
SPNDDOWNSpend Down Calculation Document
SSI/SSDI Transition Letter
SSI/SSDI Transition Letter - SpanishPDF
Standard Visitor Loginstrucciones
Temporary Assistance Diversion Transmittal FormPDF
TPL-1Third Party Resource ForminstruccionesPDF
WRKRINFOWorker Information Template
IM-7AAlternative Account Verification FormPDF
Facility Notification Information Sheet
IM-50AFGEInformation Notice-Regarding An Action Taken On Your CasePDF
IM-50EInformation Notice Regarding an Action Taken on Your CasePDF
IM-4Blind Services BrochurePDF
MO HealthNet Aged, Blind, and Disabled AppendicesPDF
IM-1MACAddendum to MO HealthNet Application: Request for Optional Cash Benefits