MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

MO HEALTHNET FOR KIDS INSURANCE COMPANY QUOTES

FROM	OFFICE ADDRESS	DATE December 27, 2013
MO	PHONE NUMBER
TO	NAME	CASE NAME
ADDRESS (STREET OR P.O. BOX NO.)	DCN NUMBER
CITY STATE ZIP

The MO HealthNet for Kids program requires that you get two quotes from private insurance companies on the cost for health insurance for your children. This form must be filled out by you, based on information that you get from the insurance companies. Please complete the form and return to the Family Support Division at the address above, or fax the form to - - . An eligibility specialist may contact the insurance company to verify the information you provide.

Name of Insurance Company:	__________________________________________________________

Telephone Number of Insurance Company:	_____________________________

Name of Contact at Insurance Company:	_____________________________

Does the policy provide coverage for all the following services? You must mark either “Yes” or “No” for each listed item.

Yes No	Yes No

Physician Care	Allergy diagnosis and treatment

Hospital – inpatient and outpatient	Mental Health: Outpatient counseling

Prescription drugs	Mental Health: Inpatient psychiatric care

Maternity care	Substance abuse / chemical dependency:

Emergency care, including ambulance	Outpatient counseling

Preventative care:	Inpatient treatment

Well-baby and pediatric care	Diagnostic (including lab and x-ray)

Routine physicals	Durable medical equipment, prosthetics

Immunization	Hospice

Vision exams and care	Home health and personal care

Hearing exams and care	Transplants

Dental exams and care	Therapy – occupation, physical and speech

Total Monthly Premium to cover ONLY children:	$______________________

Does your child have any pre-existing conditions the policy will not cover?	YES	NO

If yes, please explain:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Signature:	Date: