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-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