Missouri Family Support Division

Date:

Name:	DCN :

Address:

City, State, Zip:

MO HealthNet Review Form
Family Support Division must review information for everyone who has MO HealthNet, at least once a year. We need to complete the review to determine if you or your family members still qualify for MO HealthNet. Please help us by filling out this form. When answering the questions, please answer for every member of your household. If you don’t have enough room to answer all of the questions, complete section E or attach additional pages. If you have questions or need help with this form please call the Family Support Division Contact Center at 855-373-9994. The Social Security Number is needed only for those who have MO HealthNet or are applying for MO HealthNet. Race and ethnicity information is used in our reports. You do not have to give us that information. After you fill out the form, please sign on the last page where it says “Signature/Affidavit/Mark.” For MO HealthNet for Families, if both parents are in the home, both parents should sign this form. Please send written proof of your household income when you return this form. Proof could include paycheck stubs for the last month or a letter from your employer. If you are self-employed, send a copy of your latest tax return or self-employment records for the past year.
IMPORTANT! Return this form by **	** to the address listed below. FSD
will review it and call or send you a letter if more information is needed. Failure to return this form may result in your MO HealthNet coverage being closed.
FSD OFFICE:
ADDRESS:
CITY, STATE, ZIP:
Need help with your review? Call us at 1-855-373-4636. If you need help in a language other than English, call 1-855-373-4636 and tell the customer service representative the language you need. TTY users should call 1-800-735-2966.
Do you want to register to vote? If, so just fill out the voter registration form included with the review form and return it to the local Family Support office. If you don’t fill out the form, MO HealthNet coverage will not be affected.

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MO HEALTHNET ELIGIBILITY REVIEW FORM	Complete and return by:
SECTION A: Complete for all MO HealthNet Programs
Full Legal Name for Head of Eligibility Unit (First, Middle, Last)	DCN
Street Address	City	State	Zip
Primary Phone number	Alternate Phone
What kind of phone is this?	What kind of phone is this?
cell home work other _____________	cell home work other _____________
Email address	Preferred method of contact
*call **text email mail *we will call your primary phone unless you note otherwise. ** as capabilities allow
BELOW LIST ALL MEMBERS OF THE HOUSEHOLD. ATTACH ADDITIONAL PAGES IF NEEDED.
Name (First, Middle, Last) (Maiden)	Hispanic Yes or No	Race*/ Sex	Relationship To Parent/Guardian	Birth Date	Social Security Number
*1 White 2 Black/African American 3. Not used 4. American Indian/Alaska Native 5. Asian 6. Native Hawaiian/Pacific Islander 7. Chinese 8. Filipino 9. Japanese 10. Korean 11. Vietnamese 12. Other Asian 13. Guamanian or Chamorro 14. Samoan 15. Other 16. I prefer not to answer at this time
Is anyone in your household temporarily away from home? Yes No If Yes, Who?
If Yes, answer the following: Why is this person away?
Date this person left home:	Date this person is expected to return home?
Current address where this person resides?
Do you wish to start coverage for any of the above persons who are not currently covered by MO HealthNet?
Yes No If Yes, Who?
Is anyone in the household pregnant? Yes No
If Yes, who?	Expected due date?:
Is anyone in the household blind or disabled? Yes No If Yes, Who?
Do you have a guardian, family member, representative or someone who handles your money? Yes No
If yes, who?	Address and Telephone Number?
Has there been any change in citizenship or immigration status for individuals currently receiving MO HealthNet? Yes No If Yes, list the individual whose status has changed with the current information in the blanks.
Name	Immigration Status	Registration Number	Date of Entry

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Client Name

Client DCN

INCOME AND EXPENSES: (Please include proof of all household income and expenses. This includes but is not limited to paycheck stubs for the last 30 days; letter from employer(s); copy of latest tax return or business records if self-employed; award letter for Social Security or pensions; and health insurance.)
Is anyone in your household employed? Yes No If Yes, complete the following and attach proof:
NAME	EMPLOYER NAME	EMPLOYER PHONE	PAY RATE	PER*	CHECK DATE	START DATE	MONTHLY GROSS INCOME	TIPS, or MISC.
*Hour Day Week Every two weeks Twice monthly Month Year
Do you plan to file a federal income tax return Next Year?
Yes. If yes, please answer 1-3 No. If no, skip to question 3.
1. Will you file jointly with a spouse? Yes No
If yes, name of spouse:
2. Will you claim any dependents on your tax return? Yes No
If yes, list dependents:
3. Will you be claimed as a dependent on someone’s tax return? Yes No
If yes, please list tax filer:	How are you related to the tax filer?
Does anyone in your household operate a business or are self-employed? Yes No
If Yes, who?	If Yes, complete below and attach proof of income.
Describe the type of self-employment (babysitting, farm income, other)
Enter amount earned:	Per Hour Day Week Every two weeks Twice monthly Month
Do you expect any changes in your income or employment? ( hours worked, employer or unearned income) Yes No
If Yes explain:
Is there anyone who plans to go to work? Yes No If Yes, who?
Where?	When?

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Client Name

Client DCN

Do you or any other household member receive money from any of the following sources? Attach additional pages if needed.
Yes/ Amount	Name	Yes/ Amount	Name
Social Security	Union Funds or Pension Benefits
Supplemental Security Income (SSI)	Insurance Settlements
Alimony	Rent received from Land/Buildings
Money from others (friends, relatives, etc.)	Room and/or Board Received
Veteran’s Benefits	Armed Forces Allotment
Worker’s Compensation	Money from Sale of Property
Unemployment Compensation	Interest from Savings/Checking
Disability or Sick Benefits	Income received from Trusts
Income from Training Program	Income received from Annuities
Any other income Explain:	VA Aid and Attendance
Any other income Explain:	Any other income Explain:
Has anyone recently applied for any of the above benefits? Yes No
If Yes, explain:
Do you or any other household member expect to pay for certain things that can be deducted on your next federal tax return? Yes No
If Yes, complete the following and attach verification:
Amount	Per*	Type (Alimony, student loan, other deductions)
* Week Every two weeks Twice monthly Month Year
SECTION B: Complete for MO HealthNet for Families and Kids
HEALTH INSURANCE (other than MO HealthNet):
I/We have medical insurance. Yes No If Yes, complete the following:
NAME OF INSURED	NAME OF COMPANY	POLICY NUMBER	POLICY HOLDER	COVERAGE TYPE (DOCTOR OR HOSPITAL) IF LIMITED, EXPLAIN

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Client Name

Client DCN

Does this insurance cover family planning services? Yes No
Has anyone in your home lost or dropped health insurance since approval or last review? Yes No
If Yes, provide name(s), date and reason coverage ended.
Is health insurance available for any member of your family through an employer or other group membership? Yes No
If Yes, enter name of employer or group:
Is the insurance available for: Self Spouse Children
How much is the premium for the children? $	per month
Are both parents of all the children in the home? Yes No If No, list child (ren) and name of absent parent(s).
Child:	Absent Parent:
Child:	Absent Parent:
Do you practice joint custody with the other parent of any of the children listed above? Yes No If Yes, complete the following:
Child:	Absent Parent:
Child:	Absent Parent:
Do you have any new information about an absent parent(s)? Yes No
SECTION C: Complete for Uninsured Women’s Health Services
Is health insurance available for any female member of your family, ages 18 up to 56 years old, through an employer or other group membership? Yes No
If yes, who?	If yes, name of employer or group?
Is any female member of your family, ages 18 up to 56 years old, insured? Yes No
If yes, who?	If yes, name of insurance?
If yes, does the available health insurance cover family planning services? Yes No
Are you, any woman in your household, or any woman you are claiming as a tax dependent between the ages of 18 up to 56 in need of family planning services? in need of family planning services? Yes No
If yes, who?
SECTION D: Complete for all MO HealthNet Programs
Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage for future years, I agree to allow the Family Support Division to use income data, including information from tax returns. The Family Support Division will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next: 5 years (the maximum number of years allowed), or for a shorter number of years: 4 years 3 years 2 years 1 year Do not use information from tax returns to renew my coverage.
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Client Name

Client DCN

PLEASE READ CAREFULLY AND SIGN BELOW: (Signature of spouse in the home or the absent parent, if practicing joint custody, is also required) I/we agree to provide Social Security Numbers of all person applying for MO HealthNet as required by law. The Social Security Number is used to determine eligibility and verify information. I/we agree to be evaluated for the Health Insurance Premium Payment Program (HIPP) if I or members of the household are employed or lost employment in the last 30 days and the employer or former employer offers group health insurance. I/we agree that statements and information provided may be verified. I/we agree that I/we will report any changes in circumstances within TEN (10) DAYS of when they happen. I/we know it is against the law to obtain or attempt to obtain benefits to which I am/we are not entitled. Any false claim, statement or concealment of any material fact whatsoever, in whole or in part, may subject me/us to criminal and/or civil prosecution. I/we agree that by being determined eligible for MO HealthNet for a child who is deprived of parental support, I/we have assigned all rights to medical support to the State of Missouri, and that I/we must cooperate in establishing paternity and obtaining medical support unless I/we have good cause. Failure to cooperate does not affect my child’s eligibility. I/we understand acceptance of MO HealthNet constitutes an assignment of rights to the Department of Social Services, MO HealthNet Division for payment for medical care from a third party. I/we agree that medical information about me and /or my family can be released if needed for treatment, payment of medical expenses, health care operations, and/or to administer this program. If I am/we are found to be eligible for MO HealthNet, I/we know the State of Missouri will pay for covered services on my/our behalf and agree the state may file a claim against my/our estate to recover any assistance received. By signing this application on paper or electronically, you are giving us permission to deliver, or cause to be delivered, phone calls to you regarding your case from an automated dialing system at the primary phone number you provided on page 2. You do not have to consent to this as a part of your application. If you want to opt out of getting these calls, check here:
ATTENTION: Federal regulations require that the Missouri Department of Social Services (DSS) maintain a publicly available "Notice of Privacy Practices" that describes our policy for handling protected health information. The department has implemented a privacy policy and prepared a Notice of Privacy Practices. You may obtain a copy of this notice on the DSS Web site at http://www.dss.mo.gov/hipaa/hprivacy.pdf or from any county DSS office My signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete to the best of my knowledge.
Your Signature/Affidavit/Mark : Date:	Spouse or Second Parent Signature/Affidavit/Mark: Date:
SECTION E: Optional
ADDITIONAL INFORMATION: (If additional room is needed for any question please enter information here or attach an additional page. Attach proof of information as requested.)

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