MEMORANDUM

DISCUSSION:

Effective immediately the IM-61 Social Information Summary, IM-61B Disability Questionnaire, IM-60A Medical Report Including Physician’s Certification/Disability Evaluation, and MO 650-2616 Authorization for Disclosure of Consumer Medical/Health Information forms are revised in order to improve collection of medical information.  The IM-60 Medical Referral and Authorization form information has been incorporated into form MO 650-2616 and is obsolete.

The forms are to be used for applications and reviews for Adult MO HealthNet and Temporary Assistance cases when an applicant or participant claims to have or may have a disability.  The PDF and WORD versions of the revised forms have been updated in the online Forms Manual on the Intranet.  Additional supplies may be ordered through the Warehouse. Replace all previous versions.

Income Maintenance Manual section 205.050.20 has been updated to remove reference to the Medical Referral and Authorization (IM-60) form, and replace it with the Authorization for Disclosure of Consumer Medical/Health Information (MO 650-2616) form.

NECESSARY ACTION:

• Review this memorandum with all appropriate staff.
• Destroy/Recycle all previous versions.
• Destroy all IM-60 Medical Referral and Authorization forms.

KSO