Form Number | Title | Instructions | Word | Appendices | Excel | Letter | Spanish | |
---|---|---|---|---|---|---|---|---|
650-2616 | Authorization for Disclosure of Consumer Medical/Health Information (HIPAA) | Instructions | Spanish | |||||
Affidavit of Disaster Loss | ||||||||
Audit Document Request Form | Instructions | |||||||
Automatic Withdrawal Authorization – CHIP | ||||||||
Automatic Withdrawal Authorization – Spend Down | ||||||||
Automatic Withdrawal Authorization – TWHA | ||||||||
B-2 | Application for Services - Rehabilitation Services for the Blind | |||||||
BCC-2 | Certification of Need for Treatment | |||||||
CARS-3 | Demand Letter for Overissuance | Instructions | ||||||
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) | |||||||
CARS | Repayment Agreement | |||||||
Case Manager Performance Plan | Word | |||||||
Case Worker Performance Plan | Word | |||||||
CD-202 | Child Care Schedule Verification Request Form | Word | ||||||
CTYINFO | County Information Template (IM Forms) | Word | ||||||
DHSS Referral Letter | Word | |||||||
DHSS Referral Letter-Spend Down | Word | |||||||
DOI-1 | Referral for Investigation | Word | ||||||
FA-312 | VA Vendor | |||||||
FA-313 | VA Vendor Letter | Word | ||||||
FA-402 | Letter for FA-402’s Returned After 90 Days | Word | ||||||
FA-351 | Child Care Provider Health and Safety Information | Word | ||||||
FA-352 | Child Care Invoicing And Payment Information | |||||||
FA-700 | Confidentiality Agreement | Word | ||||||
FA-701 | FAMIS User Request | Word | ||||||
FA-702 | Request for Access to FAMIS Information | Word | ||||||
FA-703 | Access or Revocation of Profile to a FAMIS User Granted by Central Security Administrator | Word | ||||||
MO 580-2421 | Family Care Safety Registration - Child Care And Elder-Care Worker Registration | |||||||
Flow Chart for Pregnant Women Applications | ||||||||
FSD/DBH | Coversheet | |||||||
FSD/WIU | Tracking Sheet (See IM-#101 2004/IM-#5 2008) | Instructions | ||||||
IM-1 | Application for Benefits | Word | ||||||
IM-1ADP | MO HEALTHNET SOLA ADICION OPTIMIZADA - Spanish | |||||||
IM-1QMB-SLMB | Application for Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries | Spanish | ||||||
IM-1SSL | Ongoing Coverage Signature Request for Household Members | |||||||
IM-1SSL | Solicitud de Cobertura de Salud & Ayuda para Pagar los Costos | |||||||
IM-1SSL | Supplemental Form | |||||||
IM-1SSL | Participant Supplemental Form Letter | |||||||
IM-1U | MAGI Annual Review | Word | Spanish | |||||
IM-2B | Statement Of Parent Or Sighted Spouse | Instructions | Word | |||||
IM-2U | Eligibility Recording Form | Word | ||||||
IM-4EBT | EBT Information Pamphlet | Instructions | Spanish | |||||
IM-4 | Food Assistance - Large Print | |||||||
IM-4 | Information You Need About Fraud | Instructions | ||||||
IM-4FS/SR | Reporting Changes for the Food Stamp Program | Instructions | ||||||
IM-4 | Home and Community Based (HCB) Services | |||||||
IM-4 MA | Information about your Medical Assistance | Instructions | ||||||
IM-4 | Medicare Savings Program (MSP) Flyer | |||||||
IM-4 | MO HealthNet Flyer | |||||||
IM-4 | MO HealthNet for Nursing Home Care Flyer | |||||||
IM-4 | myDSS Flyer | |||||||
IM-4 PRM | MC+ for Kids Premium Amounts | |||||||
IM-4 SMHB | Show Me Healthy Babies Flyer | |||||||
IM-4 | SkillUP Brochure | |||||||
IM-4 | SkillUP Flyer | Spanish | ||||||
IM-4 | Spend Down Brochure | |||||||
IM-4 | Supplemental Nursing Care (SNC) Flyer | |||||||
IM-4 | Temporary Assistance Brochure | Spanish | ||||||
IM-4 | Ticket to Work | |||||||
IM-4 | Transitional MO HealthNet | |||||||
IM-4 | Vendor Planning Flyer | |||||||
IM-6 | Authorization for Release of Information | Word | ||||||
IM-6AR | IM Authorized Representative | Instructions | ||||||
IM-6AR | IM Authorized Representative - Spanish | Instructions | ||||||
IM-6ARLP | IM Authorized Representative - Large Print | Instructions | ||||||
IM-6ARR | IM Authorized Representative Revocation | |||||||
IM-6EBT | Authorization for Release of Information | Instructions | Word | |||||
IM-6EVS | Authorization for Verification form | |||||||
IM-6NF | Nursing Facility Authorization Form | Spanish | ||||||
IM-61DLP-OPTH | Ophthalmologist/Optometrist Information Request - Large Print | |||||||
IM-7 | Financial Information Request | Word | ||||||
IM-9 | Insurance and Prepaid Burial Letter | Instructions | Word | |||||
IM-10 | School Verification Report | Word | ||||||
IM-12 | Employment Information Request | Word | Spanish | |||||
IM-12A | New Employee Information Request | Word | Spanish | |||||
IM-12B | New Hire Information | Instructions | ||||||
IM-14 | Request for Interpretation of Policy | Word | ||||||
IM-16 | Communication Transmittal | Instructions | Word | |||||
IM-16 Log | Child Support TA Sanction Request | Excel | ||||||
IM-20 | Agreement for Direct Deposit | Word | ||||||
IM-23 | Client Services Postcard | Instructions | ||||||
IM-29 | MAGI | Word | ||||||
IM-29 | Medicaid Eligibility Authorization | Word | ||||||
IM-29 OPE | Out-of-Pocket Expenses | Word | ||||||
IM-29 PA | Provider Attestation of Physician's Order of Medical Necessity | |||||||
IM-29 SPDN | Notification of Spend Down Coverage | Word | ||||||
IM-29 TE | MO HealthNet Spend Down Transportation Expense Log | Word | ||||||
IM-30A | MA Spend Down Worksheet | Word | ||||||
IM-30B | Surplus Computation Worksheet | Word | ||||||
IM-30C | Explanation of Financial Eligibility | Word | ||||||
IM-30IBCA | Income Maintenance Budget (IBCA) | Word | ||||||
IM-31 | Appointment Letter | Word | ||||||
IM-31A | Request for Information | Instructions | Word | |||||
IM-31A | Request for Information Electronic | Word | ||||||
IM-31A | Request for Information - Spanish | Instructions | ||||||
IM-31A | PQ MAGI | |||||||
IM-31A SHMB | Request for Information Show Me Healthy Babies | Word | Spanish | |||||
IM-31A MC+ | MC+ Request for Information | Word | Spanish | |||||
IM-31F | Instructions for Making Your Food Stamp Application/Food Stamp Rights | Instructions | Spanish | |||||
IM-31M | Notification of Missed Interview | Instructions | Word | |||||
IM-31Q | Notice Of Contact Requested | Instructions | Word | |||||
IM-31SPDN | Spend Down Notification | Word | ||||||
IM-32DIV | Temporary Assistance Diversion Approval Notice | Word | ||||||
IM-32MAGI | Approval Notice | Word | Spanish | |||||
IM-32MAWD | Notice of Case Action | Word | ||||||
IM-32MC | MC+ Approval Notice (Non-premium groups) | Word | ||||||
IM-32MPW | MC+ for Pregnant Women Approval Notice | Word | ||||||
IM-32PRM | MC+ Approval Notice (Premium Group) | Word | ||||||
IM-32QMB | Notice of Approval | Word | ||||||
IM-32SLMB | Notice of Approval | Word | ||||||
IM-32SMHB | Action Notice – SMHB | Word | Spanish | |||||
IM-32SPDN | Notice of Approval for Medical Assistance Spend Down | Word | ||||||
IM-33 | Notice of Case Action | Word | Spanish | |||||
IM-33A | Notice of Temporary Assistance/Food Stamp Case Action | Word | ||||||
IM-33MAF | MAF Notice of Case Action | Word | ||||||
IM-33MAGI | MAGI Notice of Case Action | Word | ||||||
IM-33MAGI | MAGI Notice of Case Action - Spanish | Word | ||||||
IM-33MC | MC+ Notice of Denial | Word | ||||||
IM-33MCC | MC+ Notice of Action | Word | ||||||
IM-33MHF | MO HealthNet for Families Notice of Action | Word | Spanish | |||||
IM-33TMH-R | Transitional MO HealthNet Quarterly Report | Instructions | Word | |||||
IM-34 | Change of Status Summary | Word | ||||||
IM-35 | Identification Data Form | Word | ||||||
IM-36 | Vital Statistics Form | Word | ||||||
IM-37 | Insurance Form | Word | ||||||
IM-38 | IM-2 Recording Worksheet | Word | ||||||
IM-39 | Request For Employment Security Information - Outside State Of Missouri | Instructions | Word | |||||
IM-39A | Request For Public Assistance Information - Outside The State Of Missouri | Instructions | Word | |||||
IM-41TA | TANF Months Used | Word | ||||||
IM-42 | Inter-county Transfer | Word | ||||||
IM-50AA | Information Notice - Regarding an Action on Your Case | |||||||
SkillUP Providers Handbook | ||||||||
BCC-1 | BCCT Temporary Medicaid Authorization | |||||||
CARS-3 | Out State Demand Letter (OTSTAT) | Instructions | Letter | |||||
CARS-8 | Request for Reduction of Claim | Instructions | Word | |||||
CS-201 | Referral/Information for Services | Instructions | Word | Spanish | ||||
FA-402 | MO HEALTHNET Eligibility Review Information | Spanish | ||||||
Family Care Safety Registry Brochure | ||||||||
FS-1 | Application for Food Stamp Benefits | Instructions | Spanish | |||||
FSD-4 | Customer Service Form | Instructions | ||||||
HIPP-1 | Application for Health Insurance Premium Payment (HIPP) Program | Spanish | ||||||
HIPP-A | Application for Health Insurance Premium Payment (HIPP) Program | Spanish | ||||||
IM-1ADP | MO Healthnet Single Streamlined Addition | Spanish | ||||||
IM-1BCC | BCCT MA Applicaton | |||||||
IM-1CC | Child Care Application | Spanish | ||||||
IM-1CCLP | Child Care Application - Large Print | |||||||
IM-1MA | Medicaid Application/Eligibility Statement | Instructions | Appendices | Spanish | ||||
IM-1MAGW | MO HealthNet/Gateway to Better Health Application/Eligibility Statement | |||||||
IM-1REQ | Application Request Letter | Word | ||||||
IM-1SSL | Application for Health Coverage & Help Paying Costs | Letter | ||||||
IM-1TA | Application for Temporary Assistance Cash Benefits | |||||||
IM-1TASF | Application for Temporary Assistance | |||||||
IM-1U | 90-Day Letter | Word | ||||||
IM-1U MAGI | Annual Review | Word | ||||||
IM-1U MAGI | Annual Review - Spanish | |||||||
IM-2 | Application for Benefits | |||||||
IM-2 | Blind Pension Addendum | |||||||
IM-2A | Blind Pension Supplement | Instructions | Word | |||||
IM-2 | Mod Adult Adult Supplement - Spanish | |||||||
IM-2C | Expenses of Producing Income - Spanish | Spanish | ||||||
IM-2E | Notice of Requirement to Cooperate & Right to Claim Good Cause - Part 1 | |||||||
IM-2E | 2nd Notice of Right to Claim Good Cause - Part 2 | |||||||
IM-2EH | Extension for Hardship | Instructions | ||||||
IM-2QMB-SLMB | Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries Review | Word | ||||||
IM-3A | Reinvestigation Notice | Word | Spanish | |||||
IM-3EBT | Important Information About Electronic Benefit Transfer (EBT) Transactions | Instructions | Word | |||||
IM-3 | Temporary Assistance Orientation | |||||||
IM-3PRP | Personal Responsibility Plan | |||||||
IM-3TADRUG | Temporary Assistance Drug Testing Applicant Notice | Word | ||||||
IM-4 | Blind Services Brochure | |||||||
IM-4 | Annual Review Poster | |||||||
IM-4CC | Child Care Assistance Program | |||||||
IM-4 | Child Care Subsidy Brochure | Spanish | ||||||
IM-4 | Finding Help Brochure | Spanish | ||||||
IM-4 | Finding Help Brochure - Large Print | |||||||
IM-4 | Food Assistance | Spanish | ||||||
IM-4 | Hearing Rights | Instructions | ||||||
IM-4 | Hearing Rights - Spanish | Instructions | ||||||
IM-4 | Health Care | |||||||
IM-4 | Health Care - Spanish | |||||||
IM-42A | County Transfer Letter | Word | ||||||
IM-54 | Referral for Services | Word | ||||||
IM-54A | Home and Community Based Services Referral/Assessment | Instructions | ||||||
IM-55A | Transitional Medicaid Quarterly Report - 1st Quarter | Instructions | Spanish | |||||
IM-55B | Transitional Medicaid Quarterly Report - 2nd Quarter | Instructions | Word | Spanish | ||||
IM-55C | Instructions | Word | Spanish | |||||
IM-58 | Transitional MO HealthNet Suspension Notice | 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-61 | Social Information Summary | Instructions | Word | |||||
IM-61B | Disability Questionnaire | Instructions | ||||||
IM-61B | Disability Questionnaire (Informational) | Instructions | Word | |||||
IM-61C | Work History - Past 10 Years | Instructions | ||||||
IM-61D | Hospitals, Medical Facilities and Physicians Seen within the Past Year | Instructions | ||||||
IM-61D OPTH | Ophthalmologist / Optometrist Information Request | Instructions | Word | |||||
IM-61DLP OPTH | Ophthalmologist / Optometrist Information Request - Large Print | Instructions | ||||||
IM-62 | Notice of Eligibility for Nursing Facility/Other Vendor | Word | Spanish | |||||
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 PEME | Post Eligibility Medical Expense Budgeting Request | Word | ||||||
IM-63 HWD | MO HealthNet Undue Hardship Waiver Decision | Word | ||||||
IM-63 HWN | MO HealthNet Undue Hardship Waiver Letter | Word | Spanish | |||||
IM-63 HWR | MO HealthNet Undue Hardship Waiver Request | Word | Spanish | |||||
IM-64 | Request for Participant MO HealthNet Reimbursement | Instructions | Word | |||||
IM-66 MAN | Medical Appointment Notification | Word | ||||||
IM-66 MAR | Medical Appointment Notification - Authorized Representative | Word | ||||||
IM-66 MRN | Medical Appointment Reschedule Notification | Word | ||||||
IM-66 MRR | Medical Appointment Reschedule Notification - Authorized Representative | 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 | Facility Notification Information Sheet | |||||||
IM-76 | Social Security Referral Request | Instructions | ||||||
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-80 | Adverse Action Notice | Word | Spanish | |||||
IM-80A | Waiver of 10-day Advance Notice | Word | ||||||
IM-80MC | MC+ Advance Action Notice | Word | ||||||
IM-80PRE | Pre-Closing Notice | Word | Spanish | |||||
IM-80SPDN | Non-spend down to spend down Adverse Action Notice | Word | ||||||
IM-80TMH | Adverse Action Notice | Instructions | Word | Spanish | ||||
IM-82A | Notice of Vendor Termination | Word | Spanish | |||||
IM-87 | Application for State Hearing | Instructions | Word | Spanish | ||||
IM-89 | Agency Representative Food Stamp Hearing Control Log | Instructions | Word | |||||
IM-90 | Withdrawal of Request for Hearing | Instructions | Word | Spanish | ||||
IM-90A | Agency Action Rescinded | Instructions | Word | Spanish | ||||
IM-90B | Agency Action Withdrawn Participant Notification | Instructions | Word | Spanish | ||||
IM-94A | Family Child Care Provider Notice of Registration (Appr/Rej) | Word | ||||||
IM-94B | Parental Notice of Family Child Care Provider Registration (Appr/Rej) | Word | ||||||
IM-99 | Burial Fund Resource Designation | Word | Spanish | |||||
IM-102 | Food Stamp Worksheet | Word | ||||||
IM-103 | Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular Payroll | Instructions | ||||||
IM-108 | Student Income Verification | Word | Spanish | |||||
IM-110 | Statement of Loss/Replacement Request | Instructions | Word | |||||
IM-112 | Action Taken on Your Food Stamp Case | Instructions | Word | |||||
IM-113 | Replacement Request/Affidavit for Food Stamp Benefits Lost from EBT Account | Instructions | Word | |||||
IM-114 | Voluntary Repayment Authorization Form | |||||||
IM-115 | Request for Food Stamp Household Report | Instructions | Word | |||||
IM-145 | Change Report Form | Word | ||||||
IM-145B | Change Report | Word | ||||||
IM-145 OTH | Change Report Form | Word | ||||||
IM-150 | Suspending MO HealthNet Participants Form | |||||||
IM-151 | Requesting Inpatient Coverage | |||||||
IM-152 | Reporting Release of MO HealthNet Participant | |||||||
IM-160 | Advance Notice of your Administrative Disqualification Hearing | Instructions | ||||||
IM-161 | Waiver of Administrative Hearing | Instructions | ||||||
IM-161A | Withdrawal of Waiver of Administrative Hearing/DQ Consent Agreement | |||||||
IM-204 | Returned Check Register | Word | ||||||
IM-206 | Check Transmittal | Word | ||||||
IM-209 | Case Reading Form | Word | ||||||
IM-210 | Report of Food Stamp Quality Control Review | Instructions | Word | |||||
IM-210 MHN | Report of MHN Quality Control Review | Word | ||||||
IM-214 | Affidavit for Replacement Check | Instructions | Spanish | |||||
IM-215 | Affidavit of Forgery | Spanish | ||||||
IM-311 | Referral and Transmittal | Instructions | Word | |||||
IM-311Q | QC Referral For Contact/Sanction | Instructions | Word | |||||
IM-360A | Extension or Closing Summary | Word | ||||||
IM-363 | Notice of Temporary Assistance Extension for Hardship Action | Word | ||||||
IM-365 | EMCIA Cover Sheet | Word | ||||||
IM-366 | Drug Conviction Exception Determination Worksheet | Word | ||||||
IM-367 | Current Probation and Parole/Court Compliance Drug Conviction Exception Verification | Word | ||||||
IM-368 | Discharged Parolee Drug Conviction Exception Verification | Word | ||||||
Application for Other Benefits letter | Word | |||||||
Internal Inspections Report/Field Office | Instructions | Word | ||||||
IRS Notice Log | Instructions | Excel | ||||||
Menu | Adds Menu Items for IM Forms to MS Word | Word | ||||||
MO HealthNet Spend Down Discussion Checklist | Word | |||||||
MO HealthNet Spend Down Provider Form | ||||||||
MRT Checklist | MRT Checklist | Instructions | Word | |||||
PC-1 | Presumptive Eligibility Determination | Word | ||||||
PC-2 | MO HealthNet for Kids Presumptive Eligibility Determination | |||||||
PE-1 | SSL Application | Word | ||||||
PE-2 | Worksheet | Instructions | Word | |||||
PE-3 | PE Auth | Word | ||||||
PE-3 | TEMP SMHB | Word | ||||||
Program Improvement Plan | Instructions | Word | ||||||
QIT Agreement | Qualified Income Trust | |||||||
Request to Withdaraw or Close | Spanish | |||||||
Research and Evaluation Request | Instructions | Word | ||||||
Signiture Request Letter | Spanish | |||||||
SPNDDOWN | Spend Down Calculation Document | Word | ||||||
SSI/SSDI Transition Letter | Word | |||||||
SSI/SSDI Transition Letter - Spanish | Word | |||||||
Standard Visitor Log | Instructions | Word | ||||||
Temporary Assistance Diversion Transmittal Form | ||||||||
TPL-1 | Third Party Resource Form | Instructions | ||||||
WRKRINFO | Worker Information Template | Word | ||||||
IM-7A | Alternative Account Verification Form | |||||||
IM-1MC | Addendum MHABD | Word | ||||||
Facility Notification Information Sheet | Word |