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
- Word PDF Instructions
- IM-55B Transitional Medicaid Quarterly Report
- 2nd Quarter
- Word PDF Instructions
- IM-55C Transitional Medicaid Quarterly Report
- 3rd Quarter
- Word PDF Instructions
- IM-60A Medical Report Including Physician's
Certification/Disability Evaluation
- Word PDF Instructions
- IM-61 Social Information Summary
- Word PDF Instructions
- IM-61B Disability Questionnaire
- 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-64 Request for Participant MO HealthNet Reimbursement
- Word PDF Instructions
- IM-76 Social Security Referral Request
- Word PDF Instructions
- IM-78 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-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-80SPDN Non-spend down to spend down 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-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- IM-90A Agency Action Rescinded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- IM-90B Agency Action Withdrawn Participant Notification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-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-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-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-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
- INTERNAL INSPECTIONS REPORT/FIELD OFFICE
- Word PDF Instructions
- IRS NOTICE LOG
- Excel PDF Instructions
- Letterhead (County Office) County Office Letterhead
- Word PDF Instructions
- Letterhead (State Office) State Office Letterhead
- Word 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
- PC-1 Presumptive Eligibility Determination
- Word PDF Instructions
- PC-2 MO HealthNet for Kids Presumptive Eligibility Determination
- Word PDF Instructions
- Program Improvement Plan
- Word PDF Instructions
- Research and Evaluation Request
- Word PDF Instructions
- SAVE-2 Secondary SAVE Verification Request
- Word PDF Instructions
- SPNDDOWN spend down Calculation Document
- Word PDF Instructions
- Standard Visitor Log Standard Visitor Log
- Word PDF Instructions
- TPL-1 Instructions Third Party Resource Form
Instructions
- Word PDF Instructions
- VS-465 Affidavit Acknowledging Paternity
- Word PDF Instructions
- WRKRINFO Worker Information Template (IM FORMS)
- Word PDF Instructions