Form Number | Title | Instructions | Word | Spanish | Large Print | ||
---|---|---|---|---|---|---|---|
FS-1 | Application for Supplemental Nutrition Assistance Program (SNAP) | Spanish | Large Print | ||||
FS-1 DARI | درخواستی برای برنامه کمکی تغذیه تکمیلی | ||||||
FS-1 PASHTO | د اضافي تغذیې مرستې برنامې لپاره غوښتنلیک | ||||||
IM-1SSL | Application for Health Coverage and Help Paying Costs | Spanish | |||||
IM-1SSL DARI | درخواست برای پوشش بهداشت و کمک هزینه های پرداخت | ||||||
IM-1SSL PASHTO | روغتیا پوښښ لپاره غوښتنلیک او د لګښتونو تادیه کې مرسته | ||||||
IM-1TA | Application for Temporary Assistance Cash Benefits | Spanish | |||||
IM-1TASF | Application for Temporary Assistance | ||||||
IM-1TA DARI | درخواست کمک های موقت کمک های نقدی | ||||||
IM-1TA PASHTO | د لنډمهاله مرستې نغدو ګټو لپاره غوښتنلیک | ||||||
IM-1CC | Child Care Application | Spanish | Large Print | ||||
IM-1ABDS | Aged, Blind, and Disabled Supplement | Spanish | Large Print | ||||
IM-1ADP | MO HealthNet Single Streamlined Addition | Spanish | |||||
IM-1BC | Breast or Cervical Cancer Treatment (BCCT) Medical Assistance Application | ||||||
IM-1MAC | Addendum to MO HealthNet Application: Request for Optional Cash Benefits | Word | Spanish | ||||
IM-1SSL Ongoing | Ongoing Coverage Signature Request for Household Members | ||||||
B-2 | Application for Services - Rehabilitation Services for the Blind | ||||||
HIPP-1 | Application for Health Insurance Premium Payment (HIPP) Program | Spanish | |||||
HIPP-A | Application for Health Insurance Premium Payment (HIPP) Program - Care Coordinator Version | Spanish | |||||
MO 650-2616 | Authorization for Disclosure of Consumer Medical/Health Information (HIPAA) | Instructions | Spanish | Large Print | |||
MO 886-4706 | Automatic Withdrawal Authorization – CHIP/MO HealthNet for Kids (MHK) Insurance Premium Payments | ||||||
MO 886-4705 | Automatic Withdrawal Authorization – Spenddown Pay-In | ||||||
MO 886-4704 | Automatic Withdrawal Authorization – Ticket To Work Health Assurance (TWHA) | ||||||
BCC-2 | Certification of Need for Treatment | Instructions | |||||
CARS-8 | Request for Reduction of Claim | Instructions | Word | ||||
CD-202 | Child Care Schedule Verification Request Form | Word | |||||
CS-201 | Referral/Information for Child Support Services | Instructions | Spanish | ||||
FA-402 | MO HealthNet Eligibility Review Information | Spanish | |||||
FA-312 | VA Vendor | ||||||
FA-313 | VA Vendor Letter | ||||||
IM-1U Annual Review (MAGI) | MO HealthNet Annual Review | Word | Spanish | ||||
IM-1U | MO HealthNet Eligibility Review Form | Word | |||||
IM-2 BP Addendum | Blind Pension Addendum | ||||||
IM-2A | Blind Pension Supplement | Instructions | |||||
IM-2B | Statement Of Parent Or Sighted Spouse | Instructions | |||||
IM-2E Part One | Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | ||||||
IM-2E Part Two | Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | ||||||
IM-2EH | Extension for Hardship | Instructions | |||||
IM-2QMB-SLMB | Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries Review | ||||||
IM-3 Orientation | Temporary Assistance Orientation | ||||||
IM-3EBT | Important Information About Electronic Benefit Transfer (EBT) Transactions | Instructions | Word | ||||
IM-3PRP | Personal Responsibility Plan | ||||||
IM-3TADRUG | Temporary Assistance Drug Testing Applicant Notice | Word | |||||
IM-4AEG Flyer | MHN Adult Expansion (AEG) Flyer | Spanish | |||||
IM-4A2A Flyer | Alternatives to Abortion Flyer | Spanish | |||||
IM-4CC | Child Care Subsidy Brochure | Spanish | |||||
IM-4CS (CS-5) | Child Support Brochure | Spanish | |||||
IM-4EBT | EBT Card - Helpful Information | Spanish | |||||
IM-4EBT Pin Safety Flyer | EBT Card Safety Flyer | Spanish | |||||
IM-4EMPLOYMENTIMPACTS Flyer | How Employment Impacts Your Benefits | Spanish | |||||
IM-4FINDINGHELP | Finding Help Brochure | Spanish | Large Print | ||||
IM-4FOODASSISTANCE | Food Assistance Brochure | Spanish | Large Print | SNAP | |||
IM-4FRAUD | Information You Need About Fraud | ||||||
IM-4Reporting Changes for SNAP | Reporting Changes for SNAP Participants Flyer | Spanish | |||||
IM-4HCB | Home and Community Based (HCB) Services | ||||||
IM-4HEALTHCARE | Health Care Brochure | Spanish | |||||
IM-4HEARINGS | Hearings Information | Instructions | Spanish | ||||
IM-4LIHEAP | Low Income Home Energy Assistance Program (LIHEAP) Brochure | Spanish | |||||
IM-4LIHEAP Flyer | Low-Income Home Energy Assistance Program (LIHEAP) Flyer | Spanish | |||||
IM-4LIHWAP | Financial Help With Water Assistance (LIHWAP) Flyer | Spanish | |||||
IM-4MSP | Medicare Savings Program (MSP) Flyer | ||||||
IM-4MHND | MO HealthNet Nondiscrimination Notice | Spanish | |||||
IM-4MHNFLYER | MO HealthNet Flyer | ||||||
IM-4MHN Report a Change | MO HealthNet Report a Change Flyer | ||||||
IM-4MLIS | IM-4 Multi-Language Interpreter Services | ||||||
IM-4MYDSS | myDSS Flyer | ||||||
IM-4NHC | MO HealthNet for Nursing Home Care - Regional Nursing Home Offices | ||||||
IM-4PRM | MO HealthNet for Kids - CHIP Premium Chart | ||||||
IM-4RSB (RSB-1) | Rehabilitation Services for the Blind Brochure | Spanish | |||||
IM-4RSB Flyer | Rehabilitation Services for the Blind Flyer | Spanish | |||||
IM-4SKILLUP | SkillUP Brochure | Spanish | |||||
SkillUP Flyer | Spanish | ||||||
IM-4SMD | SNAP Medical Deductions for Elderly and Disabled Missourians Flyer | Spanish | |||||
IM-4SMHB | Show-Me Healthy Babies (SMHB) Program Flyer | ||||||
IM-4SNC | Supplemental Nursing Care (SNC) Flyer | ||||||
IM-4SPENDDOWN | Spend Down Brochure | ||||||
IM-4TA | Temporary Assistance Brochure | Spanish | |||||
IM-4TWHA | Ticket to Work Health Assurance Program (TWHA) Flyer | Spanish | |||||
IM-4TMH | Transitional MO HealthNet | ||||||
IM-4VENDOR PLANNING | MO HealthNet (Missouri Medicaid) Nursing Home Coverage Flyer | ||||||
IM-4MHN Annual Review Poster | MO HealthNet Annual Review Poster | ||||||
IM-6 | Authorization for Release of Information | Instructions | Word | ||||
IM-6AR | IM Authorized Representative | Spanish | Large Print | ||||
IM-6ARR | IM Authorized Representative Revocation | ||||||
IM-6NF | Nursing Facility Authorization Form | Spanish | |||||
IM-7 | Financial Information Request | Word | |||||
IM-7A | Alternative Account Verification Form | ||||||
IM-9 | Insurance and Prepaid Burial Letter | Word | |||||
IM-10 | School Verification Report | Word | |||||
IM-20 | Agreement for Direct Deposit | Word | |||||
IM-29 PA | Provider Attestation of Physician's Order of Medical Necessity | ||||||
IM-29 TE | MO HealthNet Spend Down Transportation Expense Log | Word | |||||
IM-31F | Applying for SNAP Benefits | Word | Spanish | ||||
IM-31V | Allowed Verification Form | ||||||
IM-50AA | Information Notice - Regarding an Action Taken On Your Case - Accuity | ||||||
IM-50AFGE | Information Notice - Regarding an Action Taken On Your Case - Accurint | ||||||
IM-50E | Information Notice - Regarding an Action Taken On Your Case - Equifax | ||||||
IM-55A | Transitional MO HealthNet - First Quarterly Report | Instructions | Spanish | ||||
IM-55B | Transitional MO HealthNet - Second Quarterly Report | Instructions | Word | Spanish | |||
IM-55C | Transitional MO HealthNet - Third Quarterly Report | Instructions | Word | Spanish | |||
IM-60A | Medical Report Including Physician's Certification/Disability Evaluation | Instructions | Word | ||||
FS-61 | SNAP (Food Stamps) Summary to Determine Fitness for Work | ||||||
IM-61B | Disability History | Instructions | |||||
IM-61C | Work History - Past 10 Years | Instructions | |||||
IM-61D | Provider History | Instructions | |||||
IM-61D-OPTH | Ophthalmologist / Optometrist Information Request | Instructions | Word | Large Print | |||
IM-61MRT | Medical Review Team Packet to Determine Disability | Spanish | |||||
IM-63 PEME | Post Eligibility Medical Expense Budgeting Request | Word | |||||
IM-64 | Request for Participant MO HealthNet Reimbursement | Instructions | Word | ||||
IM-68 | Visual Disability Examination Report | Word | |||||
IM-70 | Good Faith Effort to Sell Declaration | ||||||
IM-71 | Certification of Need for Psychiatric Services | ||||||
IM-72 FNIS | Facility Notification Information Sheet | Word | |||||
IM-78 | Declaration and Assessment of Assets | Instructions | Spanish | ||||
IM-79 | Intent to Transfer Assets Agreement | Word | |||||
IM-79A | Notification of Requirement to Transfer Assets | Word | |||||
IM-80A | Waiver of 10-day Advance Notice | ||||||
IM-87 | Application for State Hearing | Instructions | Word | Spanish | |||
IM-99 | Burial Fund Resource Designation | Word | Spanish | ||||
IM-103 | Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular Payroll | ||||||
IM-110 | Statement of Loss/Replacement Request | ||||||
IM-114 | Voluntary Repayment Authorization Form | ||||||
IM-145 | Change Report | Word | |||||
IM-145B | Change Report (Income only) | Word | |||||
IM-150 | Suspending Incarcerated Participants | ||||||
IM-151 | Inpatient Coverage for Incarcerated Participants | ||||||
IM-152 | Restoring a Suspended Participant Change Report | ||||||
IM-161A | Withdrawal of Waiver of Administrative Hearing Disqualification Consent Agreement | Instructions | |||||
IM-210 | Report of Food Stamp Quality Control Review | Instructions | |||||
IM-214 | Affidavit for Replacement Check | Spanish | |||||
IM-215 | Affidavit of Forgery | Spanish | |||||
IM-311 | Missouri Employment and Training Program (METP) Referral and Response | Instructions | |||||
IM-366 | Drug Conviction Exception Determination Worksheet | ||||||
CS-9 | Changing your support order | Spanish | |||||
GTBH Transition Letter | Gateway to Better Health Transition Letter | Word | |||||
MO 886-4576 | Application for Financial Help to Heat or Cool Your Home (LIHEAP) | Spanish | |||||
MO 886-4501 | MO HealthNet Spend Down Provider | ||||||
MO 886-4657 | Qualified Income Trust (QIT) | Instructions | |||||
Request to Withdraw or Close | Instructions | Word | Spanish | ||||
TPL-1 | Third Party Resource Form | Instructions | |||||
MO 886-4725 | Application for Financial Help With Water Assistance (LIHWAP) | Spanish | |||||
LIHWAP Supplier Agreement | |||||||
WA-1LR | LIHWAP Landlord Documentation Request | Spanish | |||||
MO 886-4698 | DCN Update Coversheet (for LIHEAP) | ||||||
MO 886-4461 | DSS Confidentiality | ||||||
MO 886-4697 | LIHEAP Online Access Request | ||||||
LIHEAP-1B | Information Request | ||||||
LIHEAP-1C | Low Income Interview Guide | ||||||
LIHEAP-3 | Employee Wage Documentation Report | ||||||
LIHEAP-8 | Energy Assistance Claims and Restitution | ||||||
EA-1E | Energy Assistance Landlord/Renter Documentation Request | ||||||
EA-12 | Supplier ACH/EFT Application - LIHEAP | ||||||
LIHEAP Appendix K | LIHEAP Energy Assistance Refund | ||||||
SkillUP Providers Handbook | |||||||
MO 231-0167 | Missouri Voter Registration Application | ||||||
IM-85 | Online Hearing Request | Instructions | |||||
IM-86 | Online Cancel Hearing Request | Instructions | |||||
IM-4Know Your Rights | SNAP Know Your Rights flyer | Spanish | |||||
IM-2SR | Signature Request Form | Spanish | |||||
FSD-4 | Customer Service Form | Instructions | |||||
IM-31B | Your Rights and Responsibilities as a Supplemental Nutrition Assistance Program (SNAP) Household | ||||||
IM-1MSP | Application for Medicare Savings Programs | Spanish | Large Print | ||||
IM-365P | Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) Provider Request | ||||||
LIHEAP/LIHWAP Postcard | Need Help with Utility Costs? | ||||||
myDSS Business Card | IM-4 | ||||||
IM-153 | Applying for Incarcerated Participants in Department of Corrections |