IM Forms Manual
Volume II
- IM-42A County Transfer Letter
- Word PDF Instructions
- IM-54 Referral for Services
- Word PDF Instructions
- IM-54A Home and Community Based Services Referral/Assessment
- Word PDF Instructions
- IM-55A Transitional Medicaid Quarterly Report
- 1st Quarter
- IM-55A (Spanish) Transitional Medicaid Quarterly Report
- 1st Quarter
- Word PDF Instructions
- IM-55B Transitional Medicaid Quarterly Report
- 2nd Quarter
- Word PDF Instructions
- IM-55B (Spanish) Transitional Medicaid Quarterly Report
- 2nd Quarter
- Word PDF Instructions
- IM-55C Transitional Medicaid Quarterly Report - 3rd Quarter
- Word PDF Instructions
- IM-55C (Spanish) Transitional Medicaid Quarterly Report - 3rd Quarter
- Word PDF Instructions
- IM-58 Transitional MO HealthNet Suspension Notice
- Word PDF Instructions
- IM-58 (Spanish) Transitional MO HealthNet Suspension Notice
- Word PDF Instructions
- IM-60A Medical Report Including Physician's
Certification/Disability Evaluation
- Word PDF Instructions
- FS-61 SNAP (Food Stamps) Summary to Determine Fitness for Work
- Word PDF Instructions
- IM-61 Social Information Summary
- Word PDF Instructions
- IM-61B Disability Questionnaire
- Word PDF Instructions
- IM-61B Informational Disability Questionnaire
- Word PDF Instructions
- IM-61C Work History - Past 10 Years
- Word PDF Instructions
- IM-61D Hospitals, Medical Facilities and Physicians Seen within the Past Year
- Word PDF Instructions
- IM-61D OPTH Ophthalmologist / Optometrist Information Request
- Word PDF Instructions
- IM-61DLP OPTH Ophthalmologist / Optometrist Information Request Large Print
- Word PDF Instructions
- Disability Applicant Cover Letter
- Word PDF Instructions
- IM-62 Notice of Eligibility for Nursing Facility/Other
Vendor
- Word PDF Instructions
- IM-62 (Spanish) Notice of Eligibility for Nursing
Facility/Other Vendor
- Word PDF Instructions
- IM-62 PEME Notice Of Post Eligibility Medical Expense Reduction In Surplus
- Word PDF Instructions
- IM-62 PEME-NFA PEME Facility Notification - Approval
- Word PDF Instructions
- IM-62 PEME-NFD PEME Facility Notification - Denial
- Word PDF Instructions
- IM-63 PEME Post Eligibility Medical Expense Budgeting Request
- Word PDF Instructions
- IM-63 HWD MO HealthNet Undue Hardship Waiver Decision
- Word PDF Instructions
- IM-63 HWN MO HealthNet Undue Hardship Waiver Letter
- Word PDF Instructions
- IM-63 HWN (Spanish) MO HealthNet Undue Hardship Waiver Letter
- Word PDF Instructions
- IM-63 HWR MO HealthNet Undue Hardship Waiver Request
- Word PDF Instructions
- IM-63 HWR (Spanish) MO HealthNet Undue Hardship Waiver Request
- Word PDF Instructions
- IM-64 Request for Participant MO HealthNet Reimbursement
- Word PDF Instructions
- IM-66 MAN Medical Appointment Notification
- Word PDF Instructions
- IM-66 MAR Medical Appointment Notification - Authorized Representative
- Word PDF Instructions
- IM-66 MRN Medical Appointment Reschedule Notification
- Word PDF Instructions
- IM-66 MRR Medical Appointment Reschedule Notification - Authorized Representative
- Word PDF Instructions
- IM-68 Visual Disability Examination Report
- Word PDF Instructions
- IM-70 Good Faith Effort to Sell Declaration
- Word PDF Instructions
- IM-71 Certification of Need for Psychiatric Services
- Word PDF Instructions
- IM-72 Facility Notification Information Sheet
- Word PDF Instructions
- IM-76 Social Security Referral Request
- Word PDF Instructions
- IM-78 Declaration and Assessment of Assets
- Word PDF Instructions
- IM-78 (Spanish) Declaration and Assessment of Assets
- Word PDF Instructions
- IM-79 Intent to Transfer Assets Agreement
- Word PDF Instructions
- IM-79A Notification of Requirement to Transfer
Assets
- Word PDF Instructions
- IM-80 Adverse Action Notice
- Word PDF Instructions
- IM-80 Adverse Action Notice - Spanish
- Word PDF Instructions
- IM-80A Waiver of 10-day Advance Notice
- Word PDF Instructions
- IM-80MC MC+ Advance Action Notice
- Word PDF Instructions
- IM-80PRE Pre-Closing Notice
- Word PDF Instructions
- IM-80PRE (Spanish) Pre-Closing Notice
- Word PDF Instructions
- IM-80SPDN Non-spend down to spend down Adverse
Action Notice
- Word PDF Instructions
- IM-80TMH Adverse Action Notice
- Word PDF Instructions
- IM-80TMH (Spanish) Adverse Action Notice
- Word PDF Instructions
- IM-82A Notice of Vendor Termination
- Word PDF Instructions
- IM-82A (Spanish) Notice of Vendor Termination
- Word PDF Instructions
- IM-87 Application for State Hearing
- Word PDF Instructions
- IM-87 (Spanish) Application for State Hearing
- Word PDF Instructions
- IM-89 Agency Representative Food Stamp Hearing
Control Log
- Word PDF Instructions
- IM-90 Withdrawal of Request for Hearing
- Word PDF Instructions
- IM-90 (Spanish) Withdrawal of Request for Hearing
- Word PDF Instructions
- IM-90A Agency Action Rescinded
- Word PDF Instructions
- IM-90A (Spanish) Agency Action Rescinded
- Word PDF Instructions
- IM-90B Agency Action Withdrawn Participant Notification
- Word PDF Instructions
- IM-90B (Spanish) Agency Action Withdrawn Participant Notification
- Word PDF Instructions
- IM-94A Family Child Care Provider Notice of
Registration (Appr/Rej)
- Word PDF Instructions
- IM-94B Parental Notice of Family Child Care
Provider Registration (Appr/Rej)
- Word PDF Instructions
- IM-99 Burial Fund Resource Designation
- Word PDF Instructions
- IM-99 (Spanish) Burial Fund Resource Designation
- Word PDF Instructions
- IM-102 Food Stamp Worksheet
- Word PDF Instructions
- IM-103 Electronic Benefits Transfer (EBT) Available
Date for Food Stamps on the Regular Payroll
- Word PDF Instructions
- IM-108 Student Income Verification
- Word PDF Instructions
- IM-108 (Spanish) Student Income Verification
- Word PDF Instructions
- IM-110 Statement of Loss/Replacement Request
- Word PDF Instructions
- IM-112 Action Taken on Your Food Stamp Case
- Word PDF Instructions
- IM-113 Replacement Request/Affidavit for Food
Stamp Benefits Lost from EBT Account
- Word PDF Instructions
- IM-114 Voluntary Repayment Authorization Form
- Word PDF Instructions
- IM-115 Request for Food Stamp Household Report
- Word PDF Instructions
- IM-145 Change Report Form
- Word PDF Instructions
- IM-145B Change Report
- Word PDF Instructions
- IM-145 OTH Change Report Form
- Word PDF Instructions
- IM-150 Suspending MO HealthNet Participants Form
- Word PDF Instructions
- IM-151 Requesting Inpatient Coverage
- Word PDF Instructions
- IM-152 Reporting Release of MO HealthNet Participant
- Word PDF Instructions
- IM-160 Advance Notice of your Administrative
Disqualification Hearing
- Word PDF Instructions
- IM-161 Waiver of Administrative Hearing
- Word PDF Instructions
- IM-161A Withdrawal of Waiver of Administrative
Hearing/DQ Consent Agreement
- Word PDF Instructions
- IM-204 Returned Check Register
- Word PDF Instructions
- IM-206 Check Transmittal
- Word PDF Instructions
- IM-209 Case Reading Form
- Word PDF Instructions
- IM-210 Report of Food Stamp Quality Control Review
- Word PDF Instructions
- IM-210 MHN Report of MHN Quality Control Review
- Word PDF Instructions
- IM-214 Affidavit for Replacement Check
- Word PDF Instructions
- IM-215 Affidavit of Forgery
- Word PDF Instructions
- IM-214 (Spanish) Affidavit for Replacement Check
- Word PDF Instructions
- IM-215 (Spanish) Affidavit of Forgery
- Word PDF Instructions
- IM-309I Initial Assessment (Obsolete)
- Word PDF Instructions
- IM-311 Referral and Transmittal
- Word PDF Instructions
- IM-311Q QC Referral For Contact/Sanction
- Word PDF Instructions
- IM-360A Extension or Closing Summary
- Word PDF Instructions
- IM-363 Notice of Temporary Assistance Extension
for Hardship Action
- Word PDF Instructions
- IM-365 EMCIA Cover Sheet
- Word PDF Instructions
- IM-366 Drug Conviction Exception Determination Worksheet
- Word PDF Instructions
- IM-367 Current Probation and Parole/Court Compliance Drug Conviction Exception Verification
- Word PDF Instructions
- IM-368 Discharged Parolee Drug Conviction Exception Verification
- Word PDF Instructions
- Application for Other Benefits letter
- Word PDF Instructions
- Internal Inspections Report/Field Office
- Word PDF Instructions
- IRS Notice Log
- Excel PDF Instructions
- Menu Adds Menu Items for IM Forms to MS Word
- Word PDF Instructions
- MO HealthNet Spend down Discussion Checklist
- Word PDF Instructions
- MO HealthNet Spend Down Provider Form
- Word PDF Instructions
- MO 580 2421 (FCSR/DSS) DSS Child Care Provider
Background Screening Request
- Word PDF Instructions
- MO 580 2422 (FCSR/DSS) DSS Child Care Provider
Screening; Provider Registration Renewal Background Screening Request
- Word PDF Instructions
- MRT Checklist
- Word PDF Instructions
- PC-1 Presumptive Eligibility Determination
- Word PDF Instructions
- PC-2 MO HealthNet for Kids Presumptive Eligibility Determination
- Word PDF Instructions
- PE-1 SSL Application
- Word PDF Instructions
- PE 2 Worksheet
- Word PDF Instructions
- PE-3 PE Auth
- Word PDF Instructions
- PE-3 TEMP SMHB
- Word PDF Instructions
- Program Improvement Plan
- Word PDF Instructions
- QIT Agreement Qualified Income Trust
- Word PDF Instructions
- Request to Withdaraw or Close (Spanish)
- Word PDF Instructions
- Research and Evaluation Request
- Word PDF Instructions
- SAVE-2 Secondary SAVE Verification Request
- Word PDF Instructions
- Signiture Request Letter - Spanish
- Word PDF Instructions
- SPNDDOWN spend down Calculation Document
- Word PDF Instructions
- SSI/SSDI Transition Letter
- Word PDF Instructions
- SSI/SSDI Transition Letter (Spanish)
- Word PDF Instructions
- Standard Visitor Log Standard Visitor Log
- Word PDF Instructions
- Temporary Assistance Diversion Transmittal Form
- Word PDF Instructions
- TPL-1 Third Party Resource Form
- Word PDF Instructions
- WRKRINFO Worker Information Template (IM FORMS)
- Word PDF Instructions