ADDENDUM TO MO HEALTHNET SINGLE STREAMLINED APPLICATION (IM-1SSL)

The following questions must be answered in order to determine your eligibility for MO HealthNet before January 1, 2014:

NOTE: If both parents of the child(ren) live in the same household even if unmarried you must fill out additional pages 4 and 5 of the Application for Health Coverage for the other parent.

Does anyone in your home receive other income such as child support, veteran’s benefits or Supplemental Security Benefits (SSI)?

PERSON RECEIVING	WHO PROVIDES THE MONEY?	AMOUNT RECEIVED?	HOW OFTEN RECEIVED?

What is your net worth (the value of everything you own minus any debt)?

What you own?	Value after debt?

Childcare costs may be an allowable income deduction for working families. Do you pay
Someone to care for your child? If yes, how much do you pay for childcare?
Check how often paid:	Weekly	Every Two Weeks	Twice Monthly	Monthly
Has anyone in your home lost or dropped health insurance in the past six months? If yes, provide
name(s), date and reason coverage ended:
Do any of your children have a medical condition that left untreated would result in death or serious
physical injury of the child? If yes, provide name(s) of child(ren):
If you answered yes to anyone in the household being pregnant, please list the expected due date
here:
Are you, or any woman in your household or who you are claiming as a tax dependent between the ages of 18 and 55 in need of family planning services? (Services include birth control, STD
screenings, etc.) Yes No If yes, please list individuals: