MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

PRE-CLOSING NOTICE

FROM	FSD OFFICE	DATE October 1, 2014
STREET ADDRESS
CITY	STATE MO	ZIP CODE
TO	NAME	POLICY HOLDER
ADDRESS (STREET OR PO BOX NO)	POLICY NUMBER
CITY	STATE	ZIP CODE
Based on information available to us, the following person(s) no longer meets the eligibility requirements for MO HealthNet benefits:
because
Eligibility may still exist for MO HealthNet benefits if any of the following apply:
If either of the circumstances below applies, you may go to MYDSS.MO.GOV to apply online or call the DSS contact center at 1-855-373-9994 to make application for benefits. Child receiving newborn coverage turned or is turning age one; An individual is pregnant. If any of the circumstances below apply, please contact the FSD information center at 1-855-373-4636 / 1-855-FSD-INFO to request evaluation of eligibility for MO HealthNet programs. An individual has a physical or mental disability which is expected to prevent employment for at least 12 months; An individual is blind; A change in circumstance such as change in income.
If you do not respond by action may be taken to end healthcare coverage for the person(s) listed.
FOR ALL OTHER QUESTIONS PLEASE CALL THE FSD INFORMATION NUMBER at 855-373-4636 (855-FSD-INFO).
MO 886-3902 (12-00)/E 06/2014	IM-80PRE