Forms Manual

Forms Manual

Form NumberTitleInstructionsWordPDFLarge PrintLetterSpanish
FS-1 DARIدرخواستی برای برنامه کمکی تغذیه تکمیلیPDF
FS-1 PASHTOد اضافي تغذیې مرستې برنامې لپاره غوښتنلیکPDF
IM-1SSL DARIدرخواست برای پوشش بهداشت و کمک هزینه های پرداختPDF
IM-1SSL PASHTOروغتیا پوښښ لپاره غوښتنلیک او د لګښتونو تادیه کې مرستهPDF
IM-1TA DARIدرخواست کمک های موقت کمک های نقدیPDF
IM-1TA PASHTOد لنډمهاله مرستې نغدو ګټو لپاره غوښتنلیکPDF
MO 650-2616Authorization for Disclosure of Consumer Medical/Health Information (HIPAA)InstructionsPDFLarge 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
B-2 Application for Services - Rehabilitation Services for the BlindPDF
BCC-2Certification of Need for TreatmentPDF
CARSRepayment Agreement PDF
CD-202Child Care Schedule Verification Request FormWord
FA-312 VA VendorPDF
FA-313VA Vendor LetterPDF
IM-1ADPMO HEALTHNET SOLA ADICION OPTIMIZADA - SpanishPDF
IM-1QMB-SLMBApplication for Medicare Savings for Qualified Beneficiaries or Specified Low-Income BeneficiariesPDFSpanish
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 ProgramsPDFLetter
IM-1SSL-letterParticipant Supplemental Form LetterPDF
IM-2BStatement Of Parent Or Sighted SpouseInstructionsWordPDF
IM-4EBTEBT Information PamphletInstructionsPDFSpanish
IM-4FRAUDInformation You Need About Fraud InstructionsPDF
IM-4FS/SRReporting Changes for the Food Stamp ProgramInstructionsPDF
IM-4HCBHome and Community Based (HCB) ServicesPDF
IM-4MSPMedicare Savings Program (MSP) FlyerPDF
IM-4MHNDMO HealthNet Nondiscrimination NoticePDFSpanish
IM-4MHNFLYERMO HealthNet FlyerPDF
IM-4MLISIM-4 Multi-Language Interpreter ServicesPDF
MO HealthNet for Nursing Home Care (NHC)Regional Nursing Home Offices Map/FlyerPDF
myDSS FlyerPDF
IM-4PRMMO HealthNet for Kids - CHIP Premium ChartPDF
Show Me Healthy Babies (SMHB) Program FlyerPDF
IM-4SKILLUPSkillUP BrochurePDFSpanish
SkillUP FlyerPDFSpanish
IM-4SPENDDOWNSpend Down BrochurePDF
IM-4SNCSupplemental Nursing Care (SNC) FlyerPDF
IM-4TATemporary Assistance BrochurePDFSpanish
IM-4TWHATicket to Work Health Assurance Program (TWHA)PDF
IM-4TMHTransitional MO HealthNetPDF
IM-4VENDOR PLANNINGMO HealthNet (Missouri Medicaid) Nursing Home Coverage FlyerPDF
IM-6Authorization for Release of InformationInstructionsWordPDF
IM-6ARIM Authorized RepresentativeInstructionsPDFLarge PrintSpanish
IM-6ARRIM Authorized Representative RevocationPDF
IM-6NFNursing Facility Authorization FormPDFSpanish
IM-7Financial Information RequestWord
IM-9Insurance and Prepaid Burial LetterInstructionsWordPDF
IM-10School Verification ReportWord
IM-12Employment Information RequestWordSpanish
IM-12ANew Employee Information RequestWordSpanish
IM-12BNew Hire InformationInstructions
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-31FInstructions for Making Your Food Stamp Application/Food Stamp RightsInstructionsPDFSpanish
IM-50AAInformation Notice - Regarding an Action Taken On Your CasePDF
SkillUP Providers HandbookPDF
CARS-8Request for Reduction of ClaimInstructionsWordPDF
CS-201Referral/Information for Child Support ServicesInstructionsPDFSpanish
FA-402MO HEALTHNET Eligibility Review InformationPDFSpanish
FS-1Application for Supplemental Nutrition Assistance ProgramInstructionsPDFSpanish
FSD-4Customer Service FormInstructionsPDF
HIPP-1Application for Health Insurance Premium Payment (HIPP) ProgramPDFSpanish
HIPP-AApplication for Health Insurance Premium Payment (HIPP) ProgramPDFSpanish
IM-1ADPMO Healthnet Single Streamlined AdditionPDFSpanish
IM-1BCCBCCT MA ApplicatonPDF
IM-1CCChild Care ApplicationPDFLarge PrintSpanish
IM-1ABDSAged, Blind, & Disabled SupplementPDFLarge PrintSpanish
IM-1REQApplication Request LetterWord
IM-1SSLApplication for Health Coverage & Help Paying CostsPDFLetterSpanish
IM-1TAApplication for Temporary Assistance Cash BenefitsPDF
IM-1TASFApplication for Temporary AssistancePDF
IM-1U9090-Day LetterWordPDF
IM-1U-MAGIMO HealthNet MAGI Annual ReviewWordPDFSpanish
IM-1U-MAGI-ESFormulario de Revisión de MO HealthNet - Annual Review - SpanishPDF
IM-2Blind Pension AddendumPDF
IM-2ABlind Pension SupplementInstructionsWordPDF
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 HardshipInstructionsPDF
IM-2QMB-SLMBMedicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries ReviewWordPDF
IM-3EBTImportant Information About Electronic Benefit Transfer (EBT) TransactionsInstructionsWord
IM-3Temporary Assistance OrientationPDF
IM-3PRPPersonal Responsibility PlanPDF
IM-3TADRUGTemporary Assistance Drug Testing Applicant NoticeWord
IM-4Annual Review PosterPDF
IM-4CCChild Care Subsidy BrochurePDFSpanish
IM-4FINDINGHELPFinding Help BrochurePDFLarge PrintSpanish
IM-4FOODASSISTANCEFood Assistance BrochurePDFLarge PrintSpanish
IM-4HEARINGSHearing RightsInstructionsPDF
IM-4HEARINGS-ESInformación sobre audiencias - Hearing Rights - SpanishInstructionsPDF
IM-4HEALTHCAREHealth Care BrochurePDFSpanish
IM-4HEALTHCARE-SPAtención Médica MO HealthNet - Health Care Brochure - SpanishPDF
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-61B InformationalDisability QuestionnaireInstructionsWordPDF
IM-61CWork History - Past 10 YearsInstructionsPDF
IM-61DProvider HistoryInstructionsPDF
IM-61D-OPTHOphthalmologist / Optometrist Information RequestInstructionsWordLarge Print
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-72Facility Notification Information SheetPDF
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 NoticeWordPDF
IM-82ANotice of Vendor TerminationWordSpanish
IM-87Application for State HearingInstructionsWordPDFSpanish
IM-99Burial Fund Resource DesignationWordSpanish
IM-102Food Stamp WorksheetWord
IM-103Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular PayrollInstructionsPDF
IM-108Student Income VerificationWordSpanish
IM-110Statement of Loss/Replacement RequestInstructionsWordPDF
IM-112Action Taken on Your Food Stamp CaseInstructionsWordPDF
IM-113Replacement Request/Affidavit for Food Stamp Benefits Lost from EBT AccountInstructionsWordPDF
IM-114Voluntary Repayment Authorization FormPDF
IM-145BChange Report (Income only)Word
IM-150Suspending MO HealthNet Participants FormPDF
IM-151Requesting Inpatient CoveragePDF
IM-152Reporting Release of MO HealthNet ParticipantPDF
IM-160Advance Notice of Your Administrative Disqualification HearingInstructionsPDF
IM-161Waiver of Administrative Hearing Disqualification Consent AgreementInstructionsPDF
IM-161AWithdrawal of Waiver of Administrative Hearing Disqualification Consent AgreementPDF
IM-210Report of Food Stamp Quality Control ReviewInstructionsPDF
IM-214Affidavit for Replacement CheckPDFSpanish
IM-215Affidavit of ForgeryPDFSpanish
IM-311Missouri Employment & Training Program (METP) Referral and ResponseInstructionsWordPDF
IM-366Drug Conviction Exception Determination WorksheetWord
IM-367Current Probation and Parole/Court Compliance Drug Conviction Exception VerificationWord
IM-368Discharged Parolee Drug Conviction Exception VerificationWord
MO 886-4501MO HealthNet Spend Down Provider FormPDF
MO 886-4657Qualified Income Trust (QIT)InstructionsPDF
Request to Withdraw or CloseInstructionsWordSpanish
TPL-1Third Party Resource FormInstructionsPDF
IM-7AAlternative Account Verification FormPDF
Facility Notification Information SheetWord
IM-50AFGEInformation Notice - Regarding an Action Taken On Your CasePDF
IM-50EInformation Notice - Regarding an Action Taken On Your CasePDF
IM-4RSB1Rehabilitation Services for the Blind BrochurePDFSpanish
MO 886-3846MO HealthNet Aged, Blind, and Disabled AppendicesPDF
IM-1MACAddendum to MO HealthNet Application: Request for Optional Cash BenefitsWordSpanish
IM-145Change ReportWord
IM-61MRTMedical Review Team Packet to Determine DisabilityPDF
MO 886-4576Application for Financial Help to Heat or Cool Your Home (LIHEAP)PDF
IM-4LIHEAPLow Income Home Energy Assistance Program (LIHEAP) BrochurePDF
Low-Income Home Energy Assistance Program (LIHEAP) FlyerPDF
Low-Income Home Water Assistance Program (LIHWAP) FlyerPDF