This application is for MO HealthNet for children under the age of 19, some parents and pregnant women, and uninsured women ages 18 up to but not including age 55 who want women’s health services.

Mailing Address:

Please provide your name, address, and phone numbers. Please indicate under "Message Phone Number" the number where you can be reached during regular work hours, or where we can leave a message for you.

Household Information:

List all the children, parents, step-parents or guardians in the household. It is important that you indicate the relationship of the person to you, i.e., spouse, son, daughter, etc. Race and ethnic group information is only for statistical use and is optional. The Social Security Number is required only for persons applying for MO HealthNet coverage.


In order to determine your family’s eligibility for MO HealthNet, please complete questions about family income.


For some applicants, eligibility for MO HealthNet will depend on their access to health insurance. It is important that you complete this section.

Absent Parent:

The law requires cooperation with Child Support Enforcement in obtaining payment for medical care if a parent of one of the children applying for MO HealthNet is absent from the home. This means you must cooperate in identifying the absent parent, helping locate the absent parent, helping to establish paternity and other necessary action. Failure to cooperate does not affect your child’s eligibility for MO HealthNet coverage. Your eligibility may be affected if you fail to cooperate. Your cooperation may be of value to you and your child because it might result in finding the absent parent, legally establishing the child’s paternity, and obtaining child support payments and rights to future Social Security, Veteran’s , or other governmental benefits.

If you feel it is not in your child’s best interest to pursue medical support from the absent parent, for example, past abuse or threat of abuse, let your Family Support Division eligibility specialist know. You may have "good cause" for not cooperating if your cooperation could result in physical or emotional harm to the child or to you. You will be asked to provide evidence to support your claim. You will be given a notice that will explain the circumstances under which good cause may be found, and the type of evidence or other information needed to decide your claim. You may also ask for this notice to help you decide whether or not to claim good cause.

Information Needed:

The following information may be needed prior to approving your MO HealthNet application:

  • Income verification for the past 30 days (i.e. paycheck stubs, letter from employer, federal income tax return, award letter, etc.);
  • Immigration documents showing name, immigration status, registration number and date of entry of those persons applying for MO HealthNet who are not U.S. citizens; and
  • Medical statement confirming pregnancy and expected date of delivery (if applying for MO HealthNet as a pregnant woman)

DO NOT DELAY SENDING IN YOUR APPLICATION IF YOU DO NOT HAVE THE VERIFICATION READILY AVAILABLE. You will be notified if additional information or verification is needed.

Other Important Information About MO HealthNet

If you have questions or need assistance completing the application, call toll-free 1-855-373-4636.

When your application is received, it will be reviewed and if additional information is needed, you will be contacted. If you do not have a phone, you can contact us at the above phone number a few days after you submit the application.

You will be notified by mail when we have completed our review. For pregnant women, applications are processed within 15 days. All other MO HealthNet applications are processed within 30 days. If you disagree with the decision concerning your eligibility, you may request a fair hearing within 90 days of the date of the decision.

Healthy Children and Youth Program:

If your children qualify for MO HealthNet, they can receive services through the Healthy Children and Youth (HCY) program. HCY provides primary and preventive health care. Your child can get examinations, shots, and tests that help them stay healthy or identify medical problems that may require treatment. MO HealthNet will pay for these health care services.

If you are pregnant and would like health risk appraisal and case management services, contact your local health department or call TEL-LINK (1-800-835-5465).

Rights and Responsibilities:

You must report any changes in circumstances declared in the application statement within 10 DAYS of when they happen, no matter what causes the changes. You have a continuing obligation to report and cannot wait until you are contacted.

Any information provided on the application is subject to verification by Federal, State, and Local officials. You may be denied benefits and/or be subject to criminal prosecution for knowingly providing false information. The crime of stealing or attempting to steal public assistance benefits of a value of seven hundred fifty dollars ($750.00), or more upon conviction, is punishable by imprisonment for a period not to exceed five years; or by confinement in the county jail for a period not to exceed one year; or by a fine not to exceed ten thousand dollars ($10,000.00), or both. If the value of the unlawfully obtained benefits is less than seven hundred fifty dollars ($750.00), the crime is a misdemeanor.

You are entitled to fair and equal treatment regardless of your age, sex, race, color, handicap, religion, creed, national origin, or political belief.


Please read this section carefully. The effective date of MO HealthNet coverage is based on the date your signed application is received.

By selecting "I Accept" below, I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete, to the best of my knowledge. I authorize insurers or employers to release any information on myself or my dependent(s) needed to determine eligibility for the HIPP program. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

By checking I Accept and typing my name in the " Signature/Affidavit" box on the form, I am electronically signing my application.

(All Information is transmitted over a Secure network)