Non-MAGI/Vendor Paper Forms
Paper copies of some forms are still necessary. These are primarily informational brochures. Provide copies of the appropriate forms to customers as required. Not every form is required for each application.
To download the latest Word version of each form, or for instructions on form completion, see the Forms Manual on the employee intranet. Some forms or instructions are available in .pdf format. Links are provided below.
|
Form Number |
Form Name / Information |
| Supplement to be completed with the IM-1SSL when an individual applies for MHABD. | |
| Application for Medicare Savings Programs | |
| Medicaid Application / Eligibility Statement. Used for mail in applications or home visits with MAGI, MHABD, SAB/BP, and Vendor. | |
| IM Authorized Representative | |
| IM Authorized Representative Revocation | |
| Authorization for Release of Medical/Health Information Nursing Facilities, In-Home Nursing Care Providers and others | |
|
IM-29OPE
|
Out of Pocket Expenses (download template) (instructions) |
| Provider Attestation of Physician’s Order of Medical Necessity | |
|
IM-29SPDN
|
Notification of Spend Down Coverage (download template) (instructions) |
| MO HealthNet Spend Down Transportation Expense Log (download template)
|
|
|
IM-43 |
Property Appraisal (instructions) |
|
IM-43A |
Request for Appraisal of an Undivided Interest in Property (instructions) |
| Home and Community Based Referral (instructions) | |
| Medical Report Including Physician’s Certification/Disability Evaluation (instructions) (Form MO650-2616 must be used in conjunction with this form when requesting information from a physician or medical provider.) |
|
| Social Information Summary (instructions) | |
| Disability Questionnaire (instructions) | |
| Work History – Past 10 Years (instructions) | |
| Hospitals, Medical Facilities and Physicians Seen Within the Past Year (instructions) | |
| Ophthalmologist/Optometrist Information Request (instructions) | |
| Visual Disability Examination Report | |
|
IM-72
|
Facility Notification Information Sheet |
| Declaration and Assessment of Assets (instructions) Used for mailed-in Division of Assets (FAMIS equivalent FA-478) |
|
| Intent to Transfer Assets Agreement (download template) | |
| Notification of Requirement to Transfer Assets (download template) | |
| MHABD Spend Down Discussion Checklist and instructions | |
| Spend Down Automatic Withdrawal Authorization | |
| Missouri Voter Registration Application | |
| Authorization for Disclosure of Consumer Medical/Health Information (instructions) | |
| Notice of Privacy Practices Regarding Health Information | |
|
Informational Pamphlets |
IM-4 MA; IM-4 Health Care Brochure; IM-4QMB; IM-4QMBA; IM-4 Spend Down (instructions); IM-4 Multi Language Interpreter Services; IM-4 MHN Non Discrimination English Version; IM-4 MHN Non Discrimination Spanish Version; IM-4 Hearings (instructions); IM-4 Fraud Provisions (instructions); IM-4 TWHA What You Should Know About Ticket to Work Health Assurance; IM-4 Vendor Planning; Non-Emergency Medical Transportation NEMT; Healthy Children and Youth HCY (if under age 21); IM-4 Personal Care; Health Insurance Premium Payment Program; Spend Down Frequently Asked Questions; (Provided during the interview – not filed in case record.) |
| Application for Health Insurance Premium Payment (HIPP) | |
| Secondary SAVE Verification Request |