Forms Manual

Forms Manual

Form NumberTitleInstructionsWordPDFSpanishLarge Print
FS-1Application for Supplemental Nutrition Assistance Program (SNAP)PDFSpanishLarge Print
FS-1 DARIدرخواستی برای برنامه کمکی تغذیه تکمیلیPDF
FS-1 PASHTOد اضافي تغذیې مرستې برنامې لپاره غوښتنلیکPDF
IM-1SSLApplication for Health Coverage and Help Paying CostsPDFSpanish
IM-1SSL DARIدرخواست برای پوشش بهداشت و کمک هزینه های پرداختPDF
IM-1SSL PASHTOروغتیا پوښښ لپاره غوښتنلیک او د لګښتونو تادیه کې مرستهPDF
IM-1TAApplication for Temporary Assistance Cash BenefitsPDFSpanish
IM-1TASFApplication for Temporary AssistancePDF
IM-1TA DARIدرخواست کمک های موقت کمک های نقدیPDF
IM-1TA PASHTOد لنډمهاله مرستې نغدو ګټو لپاره غوښتنلیکPDF
IM-1CCChild Care ApplicationPDFSpanishLarge Print
IM-1ABDSAged, Blind, and Disabled SupplementPDFSpanishLarge Print
IM-1ADPMO HealthNet Single Streamlined AdditionPDFSpanish
IM-1BCBreast or Cervical Cancer Treatment (BCCT) Medical Assistance ApplicationPDF
IM-1MACAddendum to MO HealthNet Application: Request for Optional Cash BenefitsWordSpanish
IM-1SSL OngoingOngoing Coverage Signature Request for Household MembersPDF
B-2Application for Services - Rehabilitation Services for the BlindPDF
HIPP-1Application for Health Insurance Premium Payment (HIPP) ProgramPDFSpanish
HIPP-AApplication for Health Insurance Premium Payment (HIPP) Program - Care Coordinator VersionPDFSpanish
MO 650-2616Authorization for Disclosure of Consumer Medical/Health Information (HIPAA)InstructionsPDFSpanishLarge Print
MO 886-4706Automatic Withdrawal Authorization – CHIP/MO HealthNet for Kids (MHK) Insurance Premium PaymentsPDF
MO 886-4705Automatic Withdrawal Authorization – Spenddown Pay-InPDF
MO 886-4704Automatic Withdrawal Authorization – Ticket To Work Health Assurance (TWHA)PDF
BCC-2Certification of Need for TreatmentInstructionsPDF
CARS-8Request for Reduction of ClaimInstructionsWordPDF
CD-202Child Care Schedule Verification Request FormWord
CS-201Referral/Information for Child Support ServicesInstructionsPDFSpanish
FA-402MO HealthNet Eligibility Review InformationPDFSpanish
FA-312VA VendorPDF
FA-313VA Vendor LetterPDF
IM-1U Annual Review (MAGI)MO HealthNet Annual ReviewWordPDFSpanish
IM-1UMO HealthNet Eligibility Review FormWord
IM-2 BP AddendumBlind Pension AddendumPDF
IM-2ABlind Pension SupplementInstructionsPDF
IM-2BStatement Of Parent Or Sighted SpouseInstructionsPDF
IM-2E Part OneNotice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support EnforcementPDF
IM-2E Part TwoSecond Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support EnforcementPDF
IM-2EHExtension for HardshipInstructionsPDF
IM-2QMB-SLMBMedicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries ReviewPDF
IM-3 OrientationTemporary Assistance OrientationPDF
IM-3EBTImportant Information About Electronic Benefit Transfer (EBT) TransactionsInstructionsWord
IM-3PRPPersonal Responsibility PlanPDF
IM-3TADRUGTemporary Assistance Drug Testing Applicant NoticeWord
IM-4AEG FlyerMHN Adult Expansion (AEG) FlyerPDFSpanish
IM-4A2A FlyerAlternatives to Abortion FlyerPDFSpanish
IM-4CCChild Care Subsidy BrochurePDFSpanish
IM-4CS (CS-5)Child Support BrochurePDFSpanish
IM-4EBTEBT Card - Helpful InformationPDFSpanish
IM-4EBT Pin Safety FlyerEBT Card Safety FlyerPDFSpanish
IM-4EMPLOYMENTIMPACTS FlyerHow Employment Impacts Your BenefitsPDFSpanish
IM-4FINDINGHELPFinding Help BrochurePDFSpanishLarge Print
IM-4FOODASSISTANCEFood Assistance BrochurePDFSpanishLarge PrintSNAP
IM-4FRAUDInformation You Need About FraudPDF
IM-4Reporting Changes for SNAPReporting Changes for SNAP Participants FlyerPDFSpanish
IM-4HCBHome and Community Based (HCB) ServicesPDF
IM-4HEALTHCAREHealth Care BrochurePDFSpanish
IM-4HEARINGSHearings InformationInstructionsPDFSpanish
IM-4LIHEAPLow Income Home Energy Assistance Program (LIHEAP) BrochurePDFSpanish
IM-4LIHEAP FlyerLow-Income Home Energy Assistance Program (LIHEAP) FlyerPDFSpanish
IM-4LIHWAPFinancial Help With Water Assistance (LIHWAP) FlyerPDFSpanish
IM-4MSPMedicare Savings Program (MSP) FlyerPDF
IM-4MHNDMO HealthNet Nondiscrimination NoticePDFSpanish
IM-4MHNFLYERMO HealthNet FlyerPDF
IM-4MHN Report a ChangeMO HealthNet Report a Change FlyerPDF
IM-4MLISIM-4 Multi-Language Interpreter ServicesPDF
IM-4MYDSSmyDSS FlyerPDF
IM-4NHCMO HealthNet for Nursing Home Care - Regional Nursing Home OfficesPDF
IM-4PRMMO HealthNet for Kids - CHIP Premium ChartPDF
IM-4RSB (RSB-1)Rehabilitation Services for the Blind BrochurePDFSpanish
IM-4RSB FlyerRehabilitation Services for the Blind FlyerPDFSpanish
IM-4SKILLUPSkillUP BrochurePDFSpanish
SkillUP FlyerPDFSpanish
IM-4SMDSNAP Medical Deductions for Elderly and Disabled Missourians FlyerPDFSpanish
IM-4SMHBShow-Me Healthy Babies (SMHB) Program FlyerPDF
IM-4SNCSupplemental Nursing Care (SNC) FlyerPDF
IM-4SPENDDOWNSpend Down BrochurePDF
IM-4TATemporary Assistance BrochurePDFSpanish
IM-4TWHATicket to Work Health Assurance Program (TWHA) FlyerPDFSpanish
IM-4TMHTransitional MO HealthNetPDF
IM-4VENDOR PLANNINGMO HealthNet (Missouri Medicaid) Nursing Home Coverage FlyerPDF
IM-4MHN Annual Review PosterMO HealthNet Annual Review PosterPDF
IM-6Authorization for Release of InformationInstructionsWordPDF
IM-6ARIM Authorized RepresentativePDFSpanishLarge Print
IM-6ARRIM Authorized Representative RevocationPDF
IM-6NFNursing Facility Authorization FormPDFSpanish
IM-7Financial Information RequestWord
IM-7AAlternative Account Verification FormPDF
IM-9Insurance and Prepaid Burial LetterWordPDF
IM-10School Verification ReportWord
IM-20Agreement for Direct DepositWord
IM-29 PAProvider Attestation of Physician's Order of Medical NecessityPDF
IM-29 TEMO HealthNet Spend Down Transportation Expense LogWord
IM-31FApplying for SNAP BenefitsWordSpanish
IM-31VAllowed Verification FormPDF
IM-50AAInformation Notice - Regarding an Action Taken On Your Case - AccuityPDF
IM-50AFGEInformation Notice - Regarding an Action Taken On Your Case - AccurintPDF
IM-50EInformation Notice - Regarding an Action Taken On Your Case - EquifaxPDF
IM-55ATransitional MO HealthNet - First Quarterly ReportInstructionsPDFSpanish
IM-55BTransitional MO HealthNet - Second Quarterly ReportInstructionsWordSpanish
IM-55CTransitional MO HealthNet - Third Quarterly ReportInstructionsWordSpanish
IM-60AMedical Report Including Physician's Certification/Disability EvaluationInstructionsWordPDF
FS-61SNAP (Food Stamps) Summary to Determine Fitness for WorkPDF
IM-61BDisability HistoryInstructionsPDF
IM-61CWork History - Past 10 YearsInstructionsPDF
IM-61DProvider HistoryInstructionsPDF
IM-61D-OPTHOphthalmologist / Optometrist Information RequestInstructionsWordLarge Print
IM-61MRTMedical Review Team Packet to Determine DisabilityPDFSpanish
IM-63 PEMEPost Eligibility Medical Expense Budgeting RequestWord
IM-64Request for Participant MO HealthNet ReimbursementInstructionsWordPDF
IM-68Visual Disability Examination ReportWordPDF
IM-70Good Faith Effort to Sell DeclarationPDF
IM-71Certification of Need for Psychiatric ServicesPDF
IM-72 FNISFacility Notification Information SheetWordPDF
IM-78Declaration and Assessment of AssetsInstructionsPDFSpanish
IM-79Intent to Transfer Assets AgreementWord
IM-79ANotification of Requirement to Transfer AssetsWord
IM-80AWaiver of 10-day Advance NoticePDF
IM-87Application for State HearingInstructionsWordPDFSpanish
IM-99Burial Fund Resource DesignationWordSpanish
IM-103Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular PayrollPDF
IM-110Statement of Loss/Replacement RequestPDF
IM-114Voluntary Repayment Authorization FormPDF
IM-145Change ReportWord
IM-145BChange Report (Income only)Word
IM-150Suspending Incarcerated ParticipantsPDF
IM-151Inpatient Coverage for Incarcerated ParticipantsPDF
IM-152Restoring a Suspended Participant Change ReportPDF
IM-161AWithdrawal of Waiver of Administrative Hearing Disqualification Consent AgreementInstructionsPDF
IM-210Report of Food Stamp Quality Control ReviewInstructionsPDF
IM-214Affidavit for Replacement CheckPDFSpanish
IM-215Affidavit of ForgeryPDFSpanish
IM-311Missouri Employment and Training Program (METP) Referral and ResponseInstructionsPDF
IM-366Drug Conviction Exception Determination WorksheetPDF
CS-9Changing your support orderPDFSpanish
GTBH Transition LetterGateway to Better Health Transition LetterWord
MO 886-4576Application for Financial Help to Heat or Cool Your Home (LIHEAP)PDFSpanish
MO 886-4501MO HealthNet Spend Down ProviderPDF
MO 886-4657Qualified Income Trust (QIT)InstructionsPDF
Request to Withdraw or CloseInstructionsWordSpanish
TPL-1Third Party Resource FormInstructionsPDF
MO 886-4725Application for Financial Help With Water Assistance (LIHWAP)PDFSpanish
LIHWAP Supplier AgreementPDF
WA-1LRLIHWAP Landlord Documentation RequestPDFSpanish
MO 886-4698DCN Update Coversheet (for LIHEAP)PDF
MO 886-4461DSS ConfidentialityPDF
MO 886-4697LIHEAP Online Access RequestPDF
LIHEAP-1BInformation RequestPDF
LIHEAP-1CLow Income Interview GuidePDF
LIHEAP-3Employee Wage Documentation ReportPDF
LIHEAP-8Energy Assistance Claims and RestitutionPDF
EA-1EEnergy Assistance Landlord/Renter Documentation RequestPDF
EA-12Supplier ACH/EFT Application - LIHEAPPDF
LIHEAP Appendix KLIHEAP Energy Assistance RefundPDF
SkillUP Providers HandbookPDF
MO 231-0167Missouri Voter Registration ApplicationPDF
IM-85Online Hearing RequestInstructionsPDF
IM-86Online Cancel Hearing RequestInstructionsPDF
IM-4Know Your RightsSNAP Know Your Rights flyerPDFSpanish
IM-2SRSignature Request FormPDFSpanish
FSD-4Customer Service FormInstructionsPDF
IM-31BYour Rights and Responsibilities as a Supplemental Nutrition Assistance Program (SNAP) Household PDF
IM-1MSPApplication for Medicare Savings ProgramsPDFSpanishLarge Print
IM-365PEmergency MO HealthNet Care for Ineligible Aliens (EMCIA) Provider RequestPDF
LIHEAP/LIHWAP PostcardNeed Help with Utility Costs?PDF
myDSS Business CardPDFIM-4
IM-153Applying for Incarcerated Participants in Department of CorrectionsPDF