IM Forms Manual

Volume I

650-2616 (HIPPA)  Authorization for Disclosure of Consumer Medical/Health Information
Word  PDF  Instructions
650-2616LP (HIPPA)  Authorization for Disclosure of Consumer Medical/Health Information - Large Print
Word  PDF  Instructions
650-2616 (HIPPA)  Authorization for Disclosure of Consumer Medical/Health Information- Spanish
Word  PDF  Instructions
Affidavit of Disaster Loss
Word  PDF  Instructions
Audit Document Request Form
Word  PDF  Instructions
Automatic Withdrawal Authorization – CHIP
Word  PDF  Instructions
Automatic Withdrawal Authorization – Spend Down
Word  PDF  Instructions
Automatic Withdrawal Authorization – TWHA
Word  PDF  Instructions
B-2  Application for Services for the Rehab Services for the Blind
Word  PDF  Instructions
BCC-1  BCCT Temporary Medicaid Authorization
Word  PDF  Instructions
BCC-2  Certification Of Need For Treatment
Word  PDF  Instructions
CARS-3  Demand Letter for Overissuance
Word  PDF  Instructions
CARS-3 (OTSTAT)  Out State Demand Letter
Word  PDF  Instructions  Scan
CARS-3-AE  Agency Error
Word  PDF  Instructions
CARS-3-IHE (SPV-N)  Inadvertent Household Error
Word  PDF  Instructions
CARS-3-IHE-H (SPV-Y)  Inadvertent Household Error Suspected Program Violation
Word  PDF  Instructions
CARS-8  Request for Reduction of Claim
Word  PDF  Instructions
CARS Repayment Agreement  
Word  PDF  Instructions
Case Manager Performance Plan
Word  PDF  Instructions
Case Worker Performance Plan
Word  PDF  Instructions
CD-202 Child Care Schedule Verification Request Form
Word  PDF  Instructions
CS-201  Referral/Information for Services
Word  PDF  Instructions
CS-201  Referral/Information for Services- Spanish
Word  PDF  Instructions
CTYINFO  County Information Template (IM Forms)
Word  PDF  Instructions
DHSS Referral Letter
Word  PDF  Instructions
DHSS Referral Letter-Spend Down
Word  PDF  Instructions
DOI-1  Referral for Investigation
Word  PDF  Instructions
FA-312  VA Vendor
Word  PDF  Instructions
FA-313  VA Vendor Letter
Word  PDF  Instructions
FA-402 Letter  Letter for FA-402’s Returned After 90 Days
Word  PDF  Instructions
FA-402 English  MO HEALTHNET Eligibility Review Information
Word  PDF  Instructions
FA-402  MO HEALTHNET Eligibility Review Information-Spanish
Word  PDF  Instructions
FA-351  Child Care Provider Health and Safety Information
Word  PDF  Instructions
FA-352  Child Care Invoicing And Payment Information
Word  PDF  Instructions
FA-700  Confidentiality Agreement
Word  PDF  Instructions
FA-701  FAMIS User Request
Word  PDF  Instructions
FA-702  Request for Access to FAMIS Information
Word  PDF  Instructions
FA-703  Access or Revocation of Profile to a FAMIS User Granted by Central Security Administrator
Word  PDF  Instructions
Family Care Safety Registration  - Child Care And Elder-Care Worker Registration MO 580-2421
Word  PDF  Instructions
Family Care Safety Registry Brochure
Word  PDF  Instructions
Flow Chart for Pregnant Women Applications
Word  PDF  Instructions
FS-1  Application for Food Stamp Benefits
Word  PDF  Instructions
FS-1   Application for Food Stamp Benefits - Spanish
Word  PDF
FSD/DBH  Coversheet
Word  PDF  Instructions
FSD-4  Customer Service Form
Word  PDF  Instructions
FSD/WIU Tracking Sheet  (See IM-#101 2004/IM-#5 2008)
Word  PDF  Instructions
HIPP-1  Application for Health Insurance Premium Payment (HIPP) Program
Word  PDF  Instructions
HIPP-1 (Spanish)  Application for Health Insurance Premium Payment (HIPP) Program
Word  PDF  Instructions
HIPP-A  Application for Health Insurance Premium Payment (HIPP) Program
Word  PDF  Instructions
HIPP-A (Spanish)  Application for Health Insurance Premium Payment (HIPP) Program
Word  PDF  Instructions
IM-1  Application for Benefits
Word  PDF  Instructions
IM-1ADP  MO HEALTHNET SINGLE STREAMLINED ADDITION
Word  PDF  Instructions
IM-1ADP (Spanish)  MO HEALTHNET SOLA ADICION OPTIMIZADA
Word  PDF  Instrucciones
IM-1BCC  BCCT MA Applicaton
Word  PDF  Instructions
IM-1CC  Child Care Application
Word  PDF  Instructions
IM-1CCLP  Child Care Application - Large Print
Word  PDF  Instructions
IM-1CC  Child Care Application - Spanish
Word  PDF  Instructions
IM-1MA  Medicaid Application/Eligibility Statement
Word  PDF  Appendices  Instructions
IM-1MA  Medicaid Application/Eligibility Statement- Spanish
Word  PDF  Appendices  Instructions
IM-1MAGW  MO HealthNet/Gateway to Better Health Application/Eligibility Statement
Word  PDF  Instructions
IM-1REQ  Application Request Letter
Word  PDF  Instructions
IM-1QMB-SLMB  Application for Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries
Word  PDF  Instructions
IM-1QMB-SLMB  Application for Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries- Spanish
Word  PDF  Instructions
IM-1SSL  Application for Health Coverage & Help Paying Costs
Word  PDF  Instructions  Signature Request Letter
IM-1SSL Solicitud de Cobertura de Salud & Ayuda para Pagar los Costos
Word  PDF  Instrucciones
IM-1SSL Supplemental Form
Word  PDF   IM-1SSL Participant Supplemental Form Letter
IM-1TA  Application for Temporary Assistance Cash Benefits
Word  PDF  Instructions
IM-1TASF  Application for Temporary Assistance
Word  PDF  Instructions
IM-1U  90-Day Letter
Word  PDF  Instructions
IM-1U MAGI  Annual Review
Word  PDF  Instructions
IM-1U MAGI  Annual Review - Spanish
Word  PDF  Instructions
IM-2  Application for Benefits
Word  PDF  Instructions
IM-2  Blind Pension Addendum
Word  PDF  Instructions
IM-2A  Blind Pension Supplement
Word  PDF  Instructions
IM-2B  Statement Of Parent Or Sighted Spouse
Word  PDF  Instructions
IM-2 Mod Adult  Adult Supplement - Spanish
Word  PDF  Instructions
IM-2C Expenses of Producing Income - Spanish
Word  PDF  Instructions
IM-2E (Pt. 1)  Notice of Requirement to Cooperate & Right to Claim Good Cause
Word  PDF  Instructions
IM-2E (Pt. 2)  2nd Notice of Right to Claim Good Cause
Word  PDF  Instructions
IM-2EH  Extension for Hardship
Word  PDF  Instructions
IM-2QMB-SLMB  Medicare Savings for Qualified Beneficiaries or Specified Low-Income Beneficiaries Review
Word  PDF  Instructions
IM-2U  Eligibility Recording Form
Word  PDF  Instructions
IM-3A  Reinvestigation Notice
Word  PDF  Instructions
IM-3A  Reinvestigation Notice - Spanish
Word  PDF  Instructions
IM-3EBT  Important Information About Electronic Benefit Transfer (EBT) Transactions
Word  PDF  Instructions
IM-3 Orientation  Temporary Assistance Orientation
Word  PDF  Instructions
IM-3PRP  Personal Responsibility Plan
Word  PDF  Instructions
IM-3TADRUG  Temporary Assistance Drug Testing Applicant Notice
Word  PDF  Instructions
IM-4  Blind Services Brochure
Word  PDF  Instructions
IM-4 Annual Review Poster
Word PDF Instructions
IM-4CC  Child Care Assistance Program
Word  PDF  Instructions
IM-4  Child Care Subsidy Brochure
Word  PDF  Instructions
IM-4  Child Care Subsidy Brochure - Spanish
Word  PDF  Instructions
IM-4EBT  EBT Information Pamphlet
Word  PDF  Instructions
IM-4EBT  EBT Information Pamphlet - Spanish
Word  PDF  Instructions
IM-4 Finding Help Brochure
Word  PDF  Instructions
IM-4 Finding Help Brochure - Large Print
Word  PDF  Instructions
IM-4 Finding Help Brochure - Spanish
Word  PDF  Instructions
IM-4 Food Assistance
Word  PDF  Instructions
IM-4 Food Assistance - Spanish
Word  PDF  Instructions
IM-4 Food Assistance - Large Print
Word  PDF  Instructions
IM-4 Fraud  Information You Need About Fraud
Word  PDF  Instructions
IM-4FS/SR  Reporting Changes for the Food Stamp Program
Word  PDF  Instructions
IM-4 Hearing Rights
Word  PDF  Instructions
IM-4  Hearing Rights - Spanish
Word  PDF  Instructions
IM-4  Health Care
Word  PDF  Instructions
IM-4  Health Care - Spanish
Word  PDF  Instructions
IM-4  Home and Community Based (HCB) Services
Word  PDF  Instructions
IM-4 MA  Information about your Medical Assistance
Word  PDF  Instructions
IM-4 Medicare Savings Program (MSP) Flyer
Word  PDF  Instructions
IM-4  MO HealthNet Flyer
Word  PDF
IM-4  MO HealthNet for Nursing Home Care Flyer
Word  PDF
IM-4 myDSS Flyer
Word  PDF  Instructions
IM-4 PRM  MC+ for Kids Premium Amounts
Word  PDF  Instructions
IM-4 SMHB  Show Me Healthy Babies Flyer
Word  PDF  Instructions
IM-4 SkillUP Brochure  
Word  PDF  Instructions
IM-4 SkillUP Flyer  
Word  PDF  Instructions
IM-4 Spend Down Brochure
Word  PDF  Instructions
IM-4 Supplemental Nursing Care (SNC) Flyer
Word  PDF  Instructions
IM-4 Temporary Assistance Brochure
Word  PDF  Instructions
IM-4 Temporary Assistance Brochure - Spanish
Word  PDF  Instructions
IM-4  Ticket to Work
Word  PDF
IM-4  Transitional MO HealthNet
Word  PDF
IM-4  Vendor Planning Flyer
Word  PDF
IM-6  Authorization for Release of Information
Word  PDF  Instructions
IM-6AR  IM Authorized Representative
Word  PDF  Instructions
IM-6AR  IM Authorized Representative - Spanish
Word  PDF  Instructions
IM-6ARLP  IM Authorized Representative - Large Print
Word  PDF  Instructions
IM-6ARR  IM Authorized Representative Revocation
Word  PDF  Instructions
IM-6EBT  Authorization for Release of Information
Word  PDF  Instructions
IM-6NF  Nursing Facility Authorization Form
Word  PDF  Instructions
IM-6NF  Nursing Facility Authorization Form- Spanish
Word  PDF  Instructions
IM-61DLP-OPTH  Ophthalmologist/Optometrist Information Request - Large Print
Word  PDF  Instructions
IM-7  Financial Information Request
Word  PDF  Instructions
IM-9  Insurance and Prepaid Burial Letter
Word  PDF  Instructions
IM-10  School Verification Report
Word  PDF  Instructions
IM-12  Employment Information Request
Word  PDF  Instructions
IM-12  Employment Information Request - Spanish
Word  PDF  Instructions
IM-12A  New Employee Information Request
Word  PDF  Instructions
IM-12A  New Employee Information Request - Spanish
Word  PDF  Instructions
IM-12B  New Hire Information
Word  PDF  Instructions
IM-14  Request for Interpretation of Policy
Word  PDF  Instructions
IM-16  Communication Transmittal
Word  PDF  Instructions
IM-16 Log   Child Support TA Sanction Request
Excel  PDF  Instructions
IM-20  Agreement for Direct Deposit
Word  PDF  Instructions
IM-23  Client Services Postcard
Word  PDF  Instructions
IM-29 MAGI
Word   PDF   Instructions
IM-29  Medicaid Eligibility Authorization
Word  PDF  Instructions
IM-29 OPE  Out-of-Pocket Expenses
Word  PDF  Instructions
IM-29 PA  Provider Attestation of Physician's Order of Medical Necessity
Word  PDF  Instructions
IM-29 SPDN  Notification of Spend Down Coverage
Word  PDF  Instructions
IM-29 TE  MO HealthNet Spend Down Transportation Expense Log
Word  PDF  Instructions
IM-30A  MA Spend Down Worksheet
Word  PDF  Instructions
IM-30B  Surplus Computation Worksheet
Word  PDF  Instructions
IM-30C  Explanation of Financial Eligibility
Word  PDF  Instructions
IM-30IBCA  Income Maintenance Budget (IBCA)
Word  PDF  Instructions
IM-31  Appointment Letter
Word  PDF  Instructions
IM-31A  Request for Information
Word  PDF  Instructions
IM-31A  Request for Information Electronic
Word  PDF  Instructions
IM-31A  Request for Information - Spanish
Word  PDF  Instructions
IM-31A   PQ MAGI
Word  PDF  Instructions
IM-31A SHMB  Request for Information Show Me Healthy Babies
Word  PDF  Instructions
IM-31A SHMB  Request for Information Show Me Healthy Babies - Spanish
Word  PDF  Instructions
IM-31A MC+  MC+ Request for Information
Word  PDF  Instructions
IM-31A MC+  MC+ Request for Information - Spanish
Word  PDF  Instructions
IM-31F  Instructions for Making Your Food Stamp Application/Food Stamp Rights
Word  PDF  Instructions
IM-31F  Instructions for Making Your Food Stamp Application/Food Stamp Rights - Spanish
Word  PDF  Instructions
IM-31M  Notification of Missed Interview
Word  PDF  Instructions
IM-31Q  Notice Of Contact Requested
Word  PDF  Instructions
IM-31SPDN  Spend Down Notification
Word  PDF  Instructions
IM-32DIV  Temporary Assistance Diversion Approval Notice
Word  PDF  Instructions
IM-32MAGI  Approval Notice
Word  PDF  Instructions
IM-32MAGI  Approval Notice - Spanish
Word  PDF  Instructions
IM-32MAWD  Notice of Case Action
Word  PDF  Instructions
IM-32MC  MC+ Approval Notice (Non-premium groups)
Word  PDF  Instructions
IM-32MPW  MC+ for Pregnant Women Approval Notice
Word  PDF  Instructions
IM-32PRM  MC+ Approval Notice (Premium Group)
Word  PDF  Instructions
IM-32QMB  Notice of Approval
Word  PDF  Instructions
IM-32SLMB  Notice of Approval
Word  PDF  Instructions
IM-32SMHB  Action Notice – SMHB
Word  PDF  Instructions
IM-32SMHB  Action Notice – SMHB - Spanish
Word  PDF  Instructions
IM-32SPDN  Notice of Approval for Medical Assistance Spend Down
Word  PDF  Instructions
IM-33  Notice of Case Action
Word  PDF  Instructions
IM-33  Notice of Case Action - Spanish
Word  PDF  Instructions
IM-33A  Notice of Temporary Assistance/Food Stamp Case Action
Word  PDF  Instructions
IM-33MAF  MAF Notice of Case Action
Word  PDF  Instructions
IM-33MAGI  MAGI Notice of Case Action
Word  PDF  Instructions
IM-33MAGI  MAGI Notice of Case Action - Spanish
Word  PDF  Instructions
IM-33MC  MC+ Notice of Denial
Word  PDF  Instructions
IM-33MCC  MC+ Notice of Action
Word  PDF  Instructions
IM-33MHF  MO HealthNet for Families Notice of Action
Word  PDF  Instructions
IM-33MHF  MO HealthNet for Families Notice of Action - Spanish
Word  PDF  Instructions
IM-33TMH-R  Transitional MO HealthNet Quarterly Report
Word  PDF  Instructions
IM-34  Change of Status Summary
Word  PDF  Instructions
IM-35  Identification Data Form
Word  PDF  Instructions
IM-36  Vital Statistics Form
Word  PDF  Instructions
IM-37  Insurance Form
Word  PDF  Instructions
IM-38  IM-2 Recording Worksheet
Word  PDF  Instructions
IM-39  Request For Employment Security Information - Outside State Of Missouri
Word  PDF  Instructions
IM-39A  Request For Public Assistance Information - Outside The State Of Missouri
Word  PDF  Instructions
IM-41TA  TANF Months Used
Word  PDF  Instructions
IM-42  Inter-county Transfer
Word  PDF  Instructions
SkillUP Flyer  
Word  PDF  Instructions
SkillUP Flyer - Spanish  
Word  PDF  Instructions
SkillUP Providers
SkillUP Providers Handbook
Appendix A Fiscal
Appendix B SkillUP Budget Template
Appendix C SkillUP Invoice
Appendix D SkillUp Expenditure temp
Appendix E SkillUP Match Form
Appendix F ABAWD Volunteer Agreement
Appendix G SkillUP Self Monitoring Template
Appendix H SkillUP Approved Services (Components)
Appendix I New Toolbox Access Form
Appendix J Alternative Access Points Policy
Appendix K DWD Services Notes Policy
Appendix L Toolbox Change Req Form
Appendix M FS_5
Appendix N Job Center WIOA Services
Appendix O Job Search Log Contract
Appendix P Job Search Log
Appendix Q Weekly Claim for Transportation-related Expenses (TRE) (when applicable)
Appendix R SkillUP Quick Guide to Training, TRE and WRE
Appendix S Supportive Service Policies (when applicable)
Central
Jefferson - Franklin
KCV & EJC
Northeast
Northwest
Ozark
South Central
Southeast
Southwest
St. Charles
St. Louis City
St. Louis County
West Central
Appendix T Civil Rights Training