Forms Manual

Forms Manual

Form NumberTitleInstructionsWordPDFLarge PrintExcelLetterSpanish
650-2616Authorization for Disclosure of Consumer Medical/Health Information (HIPAA) InstructionsPDFLarge Print
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 OverissuanceInstructions
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
CD-202Child Care Schedule Verification Request FormWord
CTYINFOCounty Information Template (IM Forms)Word
DHSS Referral LetterWord
DHSS Referral Letter-Spend DownWord
FA-312 VA VendorPDF
FA-313VA Vendor LetterPDF
FA-402Letter for FA-402’s Returned After 90 DaysWord
FA-351Child Care Provider Health and Safety InformationWord
FA-352Child Care Invoicing And Payment InformationPDF
FA-700Confidentiality AgreementWord
FA-701FAMIS User RequestWord
FA-702Request for Access to FAMIS InformationWord
FA-703Access or Revocation of Profile to a FAMIS User Granted by Central Security AdministratorWord
MO 580-2421 Family Care Safety Registration - Child Care And Elder-Care Worker RegistrationPDF
FSD/DBH Coversheet PDF
FSD/WIU Tracking Sheet (See IM-#101 2004/IM-#5 2008)InstructionsPDF
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
IM-4NHCMO HealthNet for Nursing Home Care FlyerPDF
IM-4MYDSSmyDSS FlyerPDF
IM-4PRMMO HealthNet for Kids - CHIP Premium ChartPDF
IM-4SMHBShow Me Healthy Babies FlyerPDF
IM-4SKILLUPSkillUP BrochurePDF
IM-4SKILLUPFLYERSkillUP 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-4VENDORVendor Planning FlyerPDF
IM-6Authorization for Release of InformationWordPDF
IM-6ARIM Authorized RepresentativeInstructionsPDFLarge PrintSpanish
IM-6ARRIM Authorized Representative RevocationPDF
IM-6EBTAuthorization for Release of InformationInstructionsWord
IM-6EVS Authorization for Verification formPDF
IM-6NFNursing Facility Authorization FormPDFSpanish
IM-61DLP-OPTHOphthalmologist/Optometrist Information Request - Large PrintPDF
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-14Request for Interpretation of PolicyWord
IM-16Communication TransmittalInstructionsWordPDF
IM-16 LogChild Support TA Sanction RequestExcel
IM-20Agreement for Direct DepositWord
IM-29MAGIWordPDF
IM-29Medicaid Eligibility AuthorizationWord
IM-29 OPEOut-of-Pocket ExpensesWordPDF
IM-29 PAProvider Attestation of Physician's Order of Medical NecessityPDF
IM-29 SPDNNotification of Spend Down CoverageWordPDF
IM-29 TEMO HealthNet Spend Down Transportation Expense LogWord
IM-30AMA Spend Down WorksheetWord
IM-30BSurplus Computation WorksheetWord
IM-31Appointment LetterWord
IM-31ARequest for InformationInstructionsWord
IM-31ARequest for Information ElectronicWord
IM-31ARequest for Information - SpanishInstructionsPDF
IM-31APQ MAGIPDF
IM-31A SHMBRequest for Information Show Me Healthy BabiesWordSpanish
IM-31FInstructions for Making Your Food Stamp Application/Food Stamp RightsInstructionsPDFSpanish
IM-31MNotification of Missed InterviewInstructionsWord
IM-31QNotice Of Contact RequestedInstructionsWordPDF
IM-31SPDNSpend Down NotificationWord
IM-32DIVTemporary Assistance Diversion Approval NoticeWord
IM-32MAGIApproval NoticeWordSpanish
IM-32MAWDNotice of Case ActionWord
IM-32SMHBAction Notice – SMHBWordSpanish
IM-32SPDNNotice of Approval for Medical Assistance Spend DownWord
IM-33Notice of Case ActionWordPDFSpanish
IM-33MAGIMAGI Notice of Case ActionWordPDF
IM-33MAGIMAGI Notice of Case Action - SpanishWordPDF
IM-33MHFMO HealthNet for Families Notice of ActionWordPDFSpanish
IM-33TMH-RTransitional MO HealthNet Quarterly ReportInstructionsWord
IM-39Request For Employment Security Information - Outside State Of MissouriInstructionsWordPDF
IM-39ARequest For Public Assistance Information - Outside The State Of MissouriInstructionsWordPDF
IM-41TATANF Months UsedWord
IM-50AAInformation Notice - Regarding an Action on Your CasePDF
SkillUP Providers HandbookPDF
BCC-1BCCT Temporary Medicaid AuthorizationPDF
CARS-3Out State Demand Letter (OTSTAT)InstructionsLetter
CARS-8Request for Reduction of ClaimInstructionsWordPDF
CS-201Referral/Information for Child Support ServicesInstructionsPDFSpanish
FA-402MO HEALTHNET Eligibility Review InformationPDFSpanish
Family Care Safety Registry BrochurePDF
FS-1Application for Food Stamp BenefitsInstructionsPDFSpanish
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-1MAGWMO HealthNet/Gateway to Better Health Application/Eligibility StatementPDF
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-54Referral for ServicesWord
IM-54AHome and Community Based Services Referral/AssessmentInstructionsPDF
IM-55ATransitional MO HealthNet - First Quarterly ReportInstructionsPDFSpanish
IM-55BTransitional MO HealthNet - Second Quarterly ReportInstructionsWordSpanish
IM-55CTransitional MO HealthNet - Third Quarterly ReportInstructionsWordSpanish
IM-58Transitional MO HealthNet Suspension NoticeInstructionsWordSpanish
IM-60AMedical Report Including Physician's Certification/Disability EvaluationInstructionsWordPDF
FS-61SNAP (Food Stamps) Summary to Determine Fitness for WorkPDF
IM-61Social Information SummaryInstructionsWordPDF
IM-61BDisability QuestionnaireInstructionsPDF
IM-61BDisability Questionnaire (Informational)InstructionsWordPDF
IM-61CWork History - Past 10 YearsInstructionsPDF
IM-61DHospitals, Medical Facilities and Physicians Seen within the Past YearInstructionsPDF
IM-61D OPTHOphthalmologist / Optometrist Information RequestInstructionsWordPDF
IM-61DLP OPTHOphthalmologist / Optometrist Information Request - Large PrintInstructionsPDF
IM-62Notice of Eligibility for Nursing Facility/Other VendorWordSpanish
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 RequestWord
IM-63 HWDMO HealthNet Undue Hardship Waiver DecisionWord
IM-63 HWNMO HealthNet Undue Hardship Waiver LetterWordSpanish
IM-63 HWRMO HealthNet Undue Hardship Waiver RequestWordSpanish
IM-64Request for Participant MO HealthNet ReimbursementInstructionsWordPDF
IM-66 MANMedical Appointment NotificationWord
IM-66 MARMedical Appointment Notification - Authorized RepresentativeWord
IM-66 MRNMedical Appointment Reschedule NotificationWord
IM-66 MRRMedical Appointment Reschedule Notification - Authorized RepresentativeWord
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-76Social Security Referral RequestInstructionsPDF
IM-78Declaration and Assessment of AssetsInstructionsPDFSpanish
IM-79Intent to Transfer Assets AgreementWord
IM-79ANotification of Requirement to Transfer AssetsWord
IM-80Adverse Action NoticeWordPDFSpanish
IM-80AWaiver of 10-day Advance NoticeWordPDF
IM-80PREPre-Closing NoticeWordSpanish
IM-80SPDNNon-spend down to spend down Adverse Action NoticeWordPDF
IM-80TMHAdverse Action NoticeInstructionsWordSpanish
IM-82ANotice of Vendor TerminationWordSpanish
IM-87Application for State HearingInstructionsWordPDFSpanish
IM-89Agency Representative Food Stamp Hearing Control LogInstructionsWordPDF
IM-90Withdrawal of Request for HearingInstructionsWordPDFSpanish
IM-90AAgency Action RescindedInstructionsWordSpanish
IM-90BAgency Action Withdrawn Participant NotificationInstructionsWordSpanish
IM-94AFamily Child Care Provider Notice of Registration (Appr/Rej)Word
IM-94BParental Notice of Family Child Care Provider Registration (Appr/Rej)Word
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-115Request for Food Stamp Household ReportInstructionsWord
IM-145Change Report FormWord
IM-145BChange ReportWord
IM-145 OTHChange Report FormWord
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 HearingInstructionsPDF
IM-161AWithdrawal of Waiver of Administrative Hearing/DQ Consent AgreementPDF
IM-204Returned Check RegisterWord
IM-206Check TransmittalWord
IM-210Report of Food Stamp Quality Control ReviewInstructionsWord
IM-210 MHNReport of MHN Quality Control ReviewWord
IM-214Affidavit for Replacement CheckInstructionsPDFSpanish
IM-215Affidavit of ForgeryPDFSpanish
IM-311Referral and TransmittalInstructionsWordPDF
IM-311QQC Referral For Contact/SanctionInstructionsWordPDF
IM-360AExtension or Closing SummaryWordPDF
IM-363Notice of Temporary Assistance Extension for Hardship ActionWordPDF
IM-365EMCIA Cover SheetWord
IM-366Drug Conviction Exception Determination WorksheetWord
IM-367Current Probation and Parole/Court Compliance Drug Conviction Exception VerificationWord
IM-368Discharged Parolee Drug Conviction Exception VerificationWord
Application for Other Benefits letterWord
Internal Inspections Report/Field OfficeInstructions
IRS Notice LogInstructionsExcel
MenuAdds Menu Items for IM Forms to MS WordWord
MO HealthNet Spend Down Discussion ChecklistWordPDF
MO HealthNet Spend Down Provider FormPDF
MRT ChecklistMRT ChecklistInstructionsWordPDF
PE-1SSL ApplicationWordPDF
PE-2WorksheetInstructionsWord
PE-3PE AuthWord
PE-3TEMP SMHBWord
QIT AgreementQualified Income TrustPDF
Request to Withdraw or CloseSpanish
Research and Evaluation RequestInstructionsWord
Signature Request LetterWordSpanish
SSI/SSDI Transition LetterWordSpanish
Carta Sobre Transición SSI/SSDI - SSI/SSDI Transition Letter - SpanishWordPDF
Standard Visitor LogInstructionsWord
Temporary Assistance Diversion Transmittal FormPDF
TPL-1Third Party Resource FormInstructionsPDF
WRKRINFOWorker Information TemplateWord
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 HealthNet Aged, Blind, and Disabled AppendicesPDF
IM-1MACAddendum to MO HealthNet Application: Request for Optional Cash BenefitsWordSpanish