MRT Checklist - Must be Completed & Included as Coversheet Date:

Applicant Information
DCN	NAME	Check box below if this submission is ONLY to provide verification of Earned Income and/or Medical Expenses
Financial Information
Information Verified Verified – verified information listed below N/A –no earned income in the months client is applying for coverage	Pending – earned income amounts summarized by month will be sent to MRT when verified
VERIFIED EARNED INCOME	VERIFIED MEDICAL EXPENSES
If Applicable	PQ month 1:	$	If Applicable	PQ month 1:	$
PQ month 2:	$	PQ month 2:	$
PQ month 3:	$	PQ month 3:	$
Month of app/ongoing:	$	Month of app/ongoing:	$
ES Supervisor:	BP/SAB Only App/Redetermination Yes No App/Review Date *with the exception of current medical records, all of the forms below must be submitted with the MRT Packet for a BP/SAB determination IM 68 (Visual Disability Examination Report) MO 650-2616 (Authorization for Disclosure) IM 6AR (Authorized Representative) Facility/Doctors Worksheet Current medical records included— Note: Visual Field (VF) records cannot be scanned, emailed, or faxed due to the detailed imaging included in the records. If you are submitting VF records, DO NOT scan, email or fax this packet. Submit the packet via mail to: MRT-PC at 101 Park Central Square, Springfield MO 65806
Documents Included
Included N/A	IM 365 (Emergency Medical Care for Ineligible Aliens) IM 68 (Visual Disability Examination Report) IM 61 (Social Information Summary) IM 61 Prior (for Redeterminations) IM 6AR (Authorized Representative) IM 61b (Disability Questionnaire) Facility/Doctors Worksheet Work History Worksheet MO 650-2616 (Authorization for Disclosure) Current medical records included
Note: If Guardian, Power of Attorney, or Public Administrator, etc. signed the Authorization for Disclosure on behalf of client, provide legal documentation granting such legal powers (e.g. Power of Attorney Papers) need to be included.