MISSOURI DPEARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION EMERGENCY MEDICAL CARE FOR INELIGIBLE ALIENS
PARTICIPANT NAME:	DCN:
This individual meets all criteria with the exception of citizenship/alien status and is eligible for level of care (check one):
MHABD PTD (must be MRT Approved) MHABD – OA MHK MHF UWHS MPW
MPW Non-Standard Labor and Delivery, MHABD, MHK, UWHS and MHF: Provide admission records, physician’s daily progress notes, and physician’s discharge summary. Place form on top of medical records and send to:
Family Support Division/ Medical Review Team 101 Park Central Square Springfield, MO 65806
MPW Standard Labor and Delivery requests do not require medical records. Standard Labor and Delivery: Normal Delivery – 1 day prior to birth, 2 days after birth C-Section Delivery- 1 day prior to birth, 4 days after birth
Send form as an email attachment to FSD.MEDES@dss.mo.gov.
Dates of Service Date of Admission:	Date of Discharge:
Date of Admission:	Date of Discharge:
Date of Admission:	Date of Discharge:
Date of Delivery (if applicable):
Type of delivery (Check one): NORMAL DELIVERY C-SECTION
Spend down case: YES NO Ticket to Work case: YES NO
Family Support Division office:
Eligibility Specialist:
Eligibility Specialist Supervisor:

IM-365 (10/2014)