Note: To complete fillable PDF forms, your mobile device will need Acrobat Reader and the Acrobat Fill & Sign applications.
| Form Number | Title | Instructions | Word | Spanish | Large Print | Other | Keywords | |
|---|---|---|---|---|---|---|---|---|
| FS-1 | Application for Supplemental Nutrition Assistance Program (SNAP) | Spanish | Large Print | |||||
| FS-1 DARI | درخواستی برای برنامه کمکی تغذیه تکمیلی | |||||||
| FS-1 PASHTO | د اضافي تغذیې مرستې برنامې لپاره غوښتنلیک | |||||||
| IM-1SSL | Application for Health Coverage and Help Paying Costs | Spanish | Large Print | |||||
| IM-1SSL DARI | درخواست برای پوشش بهداشت و کمک هزینه های پرداخت | |||||||
| IM-1SSL PASHTO | روغتیا پوښښ لپاره غوښتنلیک او د لګښتونو تادیه کې مرسته | |||||||
| IM-1TA | Application for Temporary Assistance Cash Benefits | Spanish | ||||||
| IM-1TASF | Application for Temporary Assistance | |||||||
| IM-1TA DARI | درخواست کمک های موقت کمک های نقدی | |||||||
| IM-1TA PASHTO | د لنډمهاله مرستې نغدو ګټو لپاره غوښتنلیک | |||||||
| IM-1ABDS | Aged, Blind, and Disabled Supplement | Spanish | Large Print | |||||
| IM-1ADP | MO HealthNet Add a Person | Spanish | ||||||
| IM-1BC | Breast or Cervical Cancer Treatment (BCCT) Medical Assistance Application | |||||||
| IM-1MAC | Addendum to MO HealthNet Application: Request for Optional Cash Benefits | Spanish | ||||||
| IM-1OSR | Ongoing Coverage Signature Request | |||||||
| B-2 | Application for Services - Rehabilitation Services for the Blind | |||||||
| HIPP-1 | Application for Health Insurance Premium Payment (HIPP) Program | Spanish | ||||||
| HIPP-A | Application for Health Insurance Premium Payment (HIPP) Program - Care Coordinator Version | Spanish | ||||||
| MO 650-2616 | Authorization for Disclosure of Consumer Medical/Health Information (HIPAA) | Instructions | Spanish | Large Print | ||||
| 2575-055 | MO HealthNet for Kids Insurance Premium Payments Automatic Withdrawal Authorization | |||||||
| 2575-056 | Spend Down Pay-In Automatic Withdrawal Authorization | |||||||
| 2575-057 | Ticket to Work Health Assurance Withdrawal Authorization | |||||||
| BCC-2 | Certification of Need for Treatment | Instructions | ||||||
| CARS-8 | Request for Reduction of Claim | Instructions | ||||||
| CD-202 | Child Care Schedule Verification Request Form | Word | ||||||
| CS-201 | Referral/Information for Child Support Services | Instructions | Spanish | |||||
| IM-312VAV | Veterans Administration Verification (Vendor) | |||||||
| IM-312VAL | Veterans Administration Vendor Letter | |||||||
| IM-2 BP Addendum | Blind Pension Addendum | |||||||
| IM-2A | Blind Pension Supplement | |||||||
| IM-2B | Statement Of Parent Or Sighted Spouse | |||||||
| IM-2E Part One | Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | |||||||
| IM-2E Part Two | Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | |||||||
| IM-2EH | Extension for Hardship | Instructions | ||||||
| IM-3Orientation | Temporary Assistance Orientation | |||||||
| IM-3EBT | Important Information About Electronic Benefit Transfer (EBT) Transactions | Instructions | Word | |||||
| IM-3PRP | Personal Responsibility Plan | |||||||
| IM-3TADRUG | Temporary Assistance Drug Testing Applicant Notice | Word | ||||||
| IM-4AEG Flyer | MHN Adult Expansion (AEG) Flyer | Spanish | ||||||
| IM-4A2A Flyer | Alternatives to Abortion Flyer | Spanish | ||||||
| CS-5 | Child Support Brochure | Spanish | ||||||
| IM-4EBT | Electronic Benefit Transfer (EBT) Card Flyer | Spanish | ||||||
| IM-4EBT Card Safety Flyer | EBT Card Safety Flyer | Spanish | pin | |||||
| IM-4Employment Impacts Benefits Flyer | How Employment Impacts Your Benefits | Spanish | ||||||
| IM-4Finding Help | Finding Help Brochure | Spanish | ||||||
| IM-4FOODASSISTANCE | Food Assistance Brochure | Spanish | SNAP | |||||
| IM-4Fraud | Information You Need About Public Assistance Fraud | Spanish | ||||||
| IM-4Reporting Changes for SNAP | Reporting Changes for SNAP Participants Flyer | Spanish | ||||||
| IM-4HCB | Home and Community Based (HCB) Services | Spanish | ||||||
| IM-4Healthcare | Health Care Brochure | Spanish | ||||||
| IM-4Hearings | Hearings Information | Spanish | ||||||
| IM-4LIHEAP | Low Income Home Energy Assistance Program (LIHEAP) Brochure | Spanish | ||||||
| IM-4LIHEAP Flyer | Low-Income Home Energy Assistance Program (LIHEAP) Flyer | Spanish | ||||||
| IM-4LIHWAP | Financial Help With Water Assistance (LIHWAP) Flyer | Spanish | ||||||
| IM-4MSP | Medicare Savings Program (MSP) Flyer | Spanish | ||||||
| IM-4MHND | MO HealthNet Nondiscrimination Notice | Spanish | ||||||
| IM-4MHN How To Use | How to use your MO HealthNet Benefit | Spanish | ||||||
| IM-4MHN Report a Change | MO HealthNet Report a Change Flyer | |||||||
| IM-4MLIS | IM-4 Multi-Language Interpreter Services | |||||||
| IM-4MYDSS | myDSS Flyer | Spanish | ||||||
| IM-4NHC | MO HealthNet for Nursing Home Care - Regional Nursing Home Offices | |||||||
| IM-4PRM | MO HealthNet for Kids - CHIP Premium Chart | |||||||
| RSB-1 | Rehabilitation Services for the Blind Brochure | Spanish | ||||||
| IM-4RSB Flyer | Rehabilitation Services for the Blind Flyer | Spanish | ||||||
| IM-4SkillUP | SkillUP Brochure | Spanish | ||||||
| IM-4SkillUP Flyer | SkillUP Flyer | Spanish | ||||||
| IM-4SMD | SNAP Medical Deductions for Elderly and Disabled Missourians Flyer | Spanish | ||||||
| IM-4SMHB | Show-Me Healthy Babies (SMHB) Program Flyer | Spanish | ||||||
| IM-4SNC | Supplemental Nursing Care (SNC) Flyer | Spanish | ||||||
| IM-4SPENDDOWN | Spend Down Flyer | Spanish | ||||||
| IM-4TA | Temporary Assistance Brochure | Spanish | ||||||
| IM-4TWHA | Ticket to Work Health Assurance Program (TWHA) Flyer | Spanish | ||||||
| IM-4TMH | Transitional MO HealthNet | Spanish | ||||||
| IM-4Vendor Planning | MO HealthNet (Missouri Medicaid) Nursing Home Coverage Flyer | Spanish | ||||||
| MO HealthNet Annual Renewal Poster | ||||||||
| IM-6 | Authorization for Release of Information | Instructions | Word | |||||
| IM-6AR | Appointing an Authorized Representative | Spanish | Large Print | |||||
| IM-6ARR | IM Authorized Representative Revocation | |||||||
| IM-6NF | Authorization for Release of Medical/Health Information to Nursing Facilities, In-Home Nursing Care Providers, and Other Providers of Medical Services | Spanish | ||||||
| IM-7 | Financial Information Request | Word | ||||||
| IM-7A | Alternative Account Verification Form | |||||||
| IM-9 | Insurance and Prepaid Burial Letter | Word | ||||||
| IM-10 | School Verification Report | Word | ||||||
| IM-20 | Agreement for Direct Deposit | Word | ||||||
| IM-29PA | Provider Attestation of Physician's Order of Medical Necessity | |||||||
| IM-29TE | MO HealthNet Spend Down Transportation Expense Log | Word | ||||||
| IM-31F | Applying for SNAP Benefits | Word | Spanish | |||||
| IM-31V | Allowed Verification Form | |||||||
| IM-50AA | Information Notice - Regarding an Action Taken On Your Case - Accuity | |||||||
| IM-50AFGE | Information Notice - Regarding an Action Taken On Your Case - Accurint | |||||||
| IM-50E | Information Notice - Regarding an Action Taken On Your Case - Equifax | |||||||
| IM-55A | Transitional MO HealthNet - First Quarterly Report | Instructions | Spanish | |||||
| IM-55B | Transitional MO HealthNet - Second Quarterly Report | Instructions | Word | Spanish | ||||
| IM-55C | Transitional MO HealthNet - Third Quarterly Report | Instructions | Word | Spanish | ||||
| IM-60A | Medical Report Including Physician's Certification/Disability Evaluation | Instructions | ||||||
| FS-61 | SNAP (Food Stamps) Summary to Determine Fitness for Work | |||||||
| IM-61B | Disability History | Instructions | ||||||
| IM-61C | Work History - Past 10 Years | Instructions | ||||||
| IM-61D | Provider History | Instructions | ||||||
| IM-61D-OPTH | Ophthalmologist / Optometrist Information Request | Instructions | Word | Large Print | ||||
| IM-61MRT | Medical Review Team Packet to Determine Disability | Spanish | ||||||
| IM-63PEME | Post Eligibility Medical Expense Budgeting Request | Word | ||||||
| IM-64 | Request for Participant MO HealthNet Reimbursement | Instructions | Word | |||||
| IM-68 | Visual Disability Examination Report | Word | ||||||
| IM-70 | Good Faith Effort to Sell Declaration | |||||||
| IM-71 | Certification of Need for Psychiatric Services | |||||||
| IM-72FNIS | Facility Notification Information Sheet | Word | ||||||
| IM-78 | Declaration and Assessment of Assets | Instructions | Spanish | |||||
| IM-79 | Intent to Transfer Assets Agreement | Word | ||||||
| IM-79A | Notification of Requirement to Transfer Assets | Word | ||||||
| IM-80A | Waiver of 10-day Advance Notice | |||||||
| IM-87 | Application for State Hearing | Instructions | Word | Spanish | ||||
| IM-99 | Burial Fund Resource Designation | Word | Spanish | |||||
| IM-103 | Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular Payroll | |||||||
| IM-110 | Replacement Request | Spanish | ||||||
| IM-114 | Voluntary Repayment Authorization Form | |||||||
| IM-145 | Change Report | Spanish | ||||||
| IM-150 | Suspending Incarcerated Participants | |||||||
| IM-151 | Inpatient Coverage for Incarcerated Participants | |||||||
| IM-152 | Restoring a Suspended Participant Change Report | |||||||
| IM-161A | Withdrawal of Waiver of Administrative Hearing Disqualification Consent Agreement | Instructions | ||||||
| IM-210 | Report of Food Stamp Quality Control Review | Instructions | ||||||
| IM-214 | Affidavit for Replacement Check | Spanish | ||||||
| IM-215 | Affidavit of Forgery | Spanish | ||||||
| IM-311 | Missouri Employment and Training Program (METP) Referral and Response | Instructions | ||||||
| IM-366 | Drug Conviction Exception Determination Worksheet | |||||||
| CS-9 | Changing your support order | Spanish | child support | |||||
| MO 886-4576 | Application for Financial Help to Heat or Cool Your Home (LIHEAP) | Spanish | ||||||
| MO 886-4501 | MO HealthNet Spend Down Provider | |||||||
| MO 886-4657 | Qualified Income Trust (QIT) | Instructions | ||||||
| IM-100RWC | Request to Withdraw or Close | Instructions | Spanish | |||||
| TPL-1 | Third Party Resource Form | Instructions | ||||||
| MO 886-4725 | Application for Financial Help With Water Assistance (LIHWAP) | Spanish | ||||||
| LIHWAP Supplier Agreement | ||||||||
| WA-1LR | LIHWAP Landlord Documentation Request | Spanish | ||||||
| MO 886-4698 | DCN Update Coversheet (for LIHEAP) | |||||||
| MO 886-4461 | DSS Confidentiality | |||||||
| MO 886-4697 | LIHEAP Online Access Request | |||||||
| LIHEAP-1B | Information Request | |||||||
| LIHEAP-1C | Low Income Interview Guide | |||||||
| LIHEAP-3 | Employee Wage Documentation Report | |||||||
| LIHEAP-8 | Energy Assistance Claims and Restitution | |||||||
| EA-1E | Energy Assistance Landlord/Renter Documentation Request | |||||||
| EA-12 | Supplier ACH/EFT Application - LIHEAP | |||||||
| LIHEAP Appendix K | LIHEAP Energy Assistance Refund | |||||||
| SkillUP Provider Handbook | ||||||||
| MO 231-0167 | Missouri Voter Registration Application | |||||||
| IM-85 | Online Hearing Request | Instructions | ||||||
| IM-86 | Online Cancel Hearing Request | Instructions | ||||||
| IM-4Know Your Rights | SNAP Know Your Rights flyer | Spanish | ||||||
| IM-2SR | Signature Request Form | Spanish | ||||||
| FSD-4 | Customer Service Form | Instructions | Spanish | |||||
| IM-31B | Your Rights and Responsibilities as a Supplemental Nutrition Assistance Program (SNAP) Household | |||||||
| IM-1MSP | Application for Medicare Savings Programs | Spanish | Large Print | |||||
| IM-365P | Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) Provider Request | |||||||
| LIHEAP/LIHWAP Postcard | Need Help with Utility Costs? | |||||||
| myDSS Business Card | IM-4 | |||||||
| IM-153 | Applying for Incarcerated Participants in Department of Corrections | |||||||
| IM-583SO | School Outreach Flyer | Spanish | Other | MO HealthNet for Kids | ||||
| IM-583CCO | Childcare Outreach Flyer | Instructions | Spanish | Other | Facility, MO HealthNet for Kids, spreadsheet | |||
| IM-4SkillUP/ABAWD | SkillUP/ABAWD Mailer | Spanish | Able-Bodied Adults Without Dependents | |||||
| IM-4MWA Flyer | Employment & Training Support for Temporary Assistance Participants | Spanish | ||||||
| IM-4BPIL Chart | Benefit Program Income Limits | |||||||
| IM-111 | Electronically Stolen Benefit Replacement Request | |||||||
| IM-4Supporting Through Change | Supporting Children & Families Through Change Flyer | Spanish | ||||||
| IM-4UPLOAD | FSD Document Upload Portal Flyer | Spanish | ||||||
| IM-63HWR | MO HealthNet Undue Hardship Waiver Request | Spanish | ||||||
| MO 886-4560 | Consumer's Authorization for Disclosure of Confidential Information | Word | child support, fatherhood, outreach, css, consumers | |||||
| MOSB-1 | Application for Missouri SuN Bucks | Spanish |