MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

REQUEST FOR PARTICIPANT MO HEALTHNET REIMBURSEMENT

TO	MO HealthNet Division Participant Services Unit 615 Howerton Ct. PO BOX 6500 Jefferson City, Mo 65102	FROM	FSD OFFICE	DATE February 11, 2013
ELIGIBLITY SPECIALIST	TELEPHONE NUMBER - -
RE	CLAIMANT'S NAME 0 DCN 0	CLAIMANT'S SPOUSE 0 DCN 0
SECTION A
HAVE YOU MADE PAYMENT FOR ANY MEDICAL SERVICES WHICH YOU OR A MEMBER OF YOUR ASSISTANCE GROUP RECEIVED FROM :
MO	DAY	YR	MO	DAY	YR	?	NO	YES
TO
CLAIMANT'S SIGNATURE	DATE	ELIGIBILITY SPECIALIST SIGNATURE	DATE
SECTION B
CLAIMANT DETERMINED ELIGIBLE FOR THE ABOVE PERIOD. IF NO, STOP AND SEND FORM TO MHD. IF YES, COMPLETE FORM.	NO NO	YES
SECTION C
WHAT WERE THE CIRCUMSTANCES WHICH PROMPTED THE AGENCY ACTION TO REVERSE THE ORIGINAL DENIAL OF ELIGIBILITY?
IS SPEND DOWN INVOLVED?	NO	YES
IF YES, ENTER THE DATES DURING THE ABOVE TIME PERIOD THAT THE CLAIMANT WAS ELIGIBLE, HAVING MET THE SPEND DOWN AMOUNT:
Month	Effective date	Month	Effective date	Month	Effective date	Month	Effective date	Month	Effective date
January	February	March	April	May
Month	Effective date	Month	Effective date	Month	Effective date	Month	Effective date	Month	Effective date
June	July	August	September	October
Month	Effective date	Month	Effective date
November	December
IF MORE THAN 12 MONTHS ARE INVOLVED, PLEASE SPECIFY:
OTHER MEMBERS OF THE ASSISTANCE GROUP ELIGIBLE DURING THE ABOVE PERIOD:
NAME	DCN
MO 866-0745 (02/2013)	DISTRIBUTION: ONE COPY TO MHD/ ONE COPY IN FILE	IM-64 (02/2013)