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 | ||
|---|---|---|---|---|---|---|---|---|
| FS-1 | Application for Supplemental Nutrition Assistance Program (SNAP) | https://dssmanuals.mo.gov/wp-content/uploads/2022/06/snap-application.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/06/snap-application-spanish.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/01/fs-1-large-print.pdf | ||||
| FS-1 DARI | درخواستی برای برنامه کمکی تغذیه تکمیلی | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/fs-1-dari.pdf | ||||||
| FS-1 PASHTO | د اضافي تغذیې مرستې برنامې لپاره غوښتنلیک | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/fs-1-pashto.pdf | ||||||
| IM-1SSL | Application for Health Coverage and Help Paying Costs | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/IM-1SSL-Fillable-Secured-6-24-21.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/im-1sslsp.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/09/im-1ssl-lp.pdf | ||||
| IM-1SSL DARI | درخواست برای پوشش بهداشت و کمک هزینه های پرداخت | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/im-1ssl-dari.pdf | ||||||
| IM-1SSL PASHTO | روغتیا پوښښ لپاره غوښتنلیک او د لګښتونو تادیه کې مرسته | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/im-1ssl-pashto.pdf | ||||||
| IM-1TA | Application for Temporary Assistance Cash Benefits | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-1ta.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/im-1ta-spanish.pdf | |||||
| IM-1TASF | Application for Temporary Assistance | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-1tasf.pdf | ||||||
| IM-1TA DARI | درخواست کمک های موقت کمک های نقدی | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/im-1ta-dari.pdf | ||||||
| IM-1TA PASHTO | د لنډمهاله مرستې نغدو ګټو لپاره غوښتنلیک | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/im-1ta-pashto.pdf | ||||||
| IM-1ABDS | Aged, Blind, and Disabled Supplement | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-1ABDS.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-1ABDS_Spanish.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-1ABDS_Large_Print.pdf | ||||
| IM-1ADP | MO HealthNet Add a Person | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-1adp.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/im-1adpsp.pdf | |||||
| IM-1BC | Breast or Cervical Cancer Treatment (BCCT) Medical Assistance Application | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-1bcc.pdf | ||||||
| IM-1MAC | Addendum to MO HealthNet Application: Request for Optional Cash Benefits | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/im1mac_fillable-v.3.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM1MAC_ES-fillable.pdf | |||||
| IM-1OSR | Ongoing Coverage Signature Request | https://dssmanuals.mo.gov/wp-content/uploads/2020/12/im-1ssl-ongoing-coverage.pdf | ||||||
| B-2 | Application for Services - Rehabilitation Services for the Blind | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/b-2.pdf | ||||||
| HIPP-1 | Application for Health Insurance Premium Payment (HIPP) Program | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/hipp-1.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/hipp-1-spanish.pdf | |||||
| HIPP-A | Application for Health Insurance Premium Payment (HIPP) Program - Care Coordinator Version | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/hipp-a.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/hipp-a-spanish.pdf | |||||
| MO 650-2616 | Authorization for Disclosure of Consumer Medical/Health Information (HIPAA) | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/650-2616-inst.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/11/650-2616-HIPPA-Authorization.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/650-2616_ES-fillable.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/650-2616LP-Authorization-for-Disclosure-of-Consumer-Medical-Health-Information-Large-Print.pdf | |||
| 2575-055 | MO HealthNet for Kids Insurance Premium Payments Automatic Withdrawal Authorization | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/chip-awa.pdf | ||||||
| 2575-056 | Spend Down Pay-In Automatic Withdrawal Authorization | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/spenddown-awa.pdf | ||||||
| 2575-057 | Ticket to Work Health Assurance Withdrawal Authorization | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/ticket-to-work-health-assurance-awa.pdf | ||||||
| BCC-2 | Certification of Need for Treatment | https://dssmanuals.mo.gov/wp-content/themes/mogovwp_dssmanuals/public/memos/memos_07/im111_07_att_bcc2instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/bcc2_0901.pdf | |||||
| CARS-8 | Request for Reduction of Claim | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/cars-8.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/cars8.pdf | |||||
| CS-201 | Referral/Information for Child Support Services | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/cs-201-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/886-0292s-CS-201-4-2021.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/CS-201-spanish.pdf | ||||
| IM-312VAV | Veterans Administration Verification (Vendor) | https://dssmanuals.mo.gov/wp-content/uploads/2020/02/FA-312-VA-Vendor.pdf | ||||||
| IM-312VAL | Veterans Administration Vendor Letter | https://dssmanuals.mo.gov/wp-content/uploads/2020/02/FA-313-VA-Vendor-Letter.pdf | ||||||
| IM-2 BP Addendum | Blind Pension Addendum | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-2-blind-pension-addendum.pdf | ||||||
| IM-2A | Blind Pension Supplement | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-2a.pdf | ||||||
| IM-2B | Statement Of Parent Or Sighted Spouse | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/im-2b.pdf | ||||||
| IM-2E Part One | Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-2e-pt1.pdf | ||||||
| IM-2E Part Two | Second Notice of Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-2e-pt2.pdf | ||||||
| IM-2EH | Extension for Hardship | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-2eh-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-2eh.pdf | |||||
| IM-3Orientation | Temporary Assistance Orientation | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/IM-3-orientation.pdf | ||||||
| IM-3EBT | Important Information About Electronic Benefit Transfer (EBT) Transactions | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-3ebt-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/IM-3ebt.docx | |||||
| IM-3PRP | Personal Responsibility Plan | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-3prp.pdf | ||||||
| IM-3TADRUG | Temporary Assistance Drug Testing Applicant Notice | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-3tadrug.docx | ||||||
| IM-4AEG Flyer | MHN Adult Expansion (AEG) Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/aeg-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/aeg-flyer-spanish.pdf | |||||
| IM-4A2A Flyer | Alternatives to Abortion Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-4a2a-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-4a2a-flyer-spanish.pdf | |||||
| CS-5 | Child Support Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/child-support-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/child-support-brochure-spanish.pdf | |||||
| IM-4EBT | Electronic Benefit Transfer (EBT) Card Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2023/06/ebt-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/06/ebt-flyer-spanish.pdf | |||||
| IM-4EBT Card Safety Flyer | EBT Card Safety Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/ebt-pin-safety.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/ebt-pin-safety-spanish.pdf | pin | ||||
| IM-4Employment Impacts Benefits Flyer | How Employment Impacts Your Benefits | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/employment-impacts-benefits-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/employment-impacts-benefits-flyer-spanish.pdf | |||||
| IM-4Finding Help | Finding Help Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/finding-help-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/finding-help-brochure-spanish.pdf | |||||
| IM-4FOODASSISTANCE | Food Assistance Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/food-assistance-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/food-assistance-brochure-spanish.pdf | SNAP | ||||
| IM-4Fraud | Information You Need About Public Assistance Fraud | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/im4fraud.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2024/05/im-4fraud-es.pdf | |||||
| IM-4Reporting Changes for SNAP | Reporting Changes for SNAP Participants Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/reporting-changes-snap.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/reporting-changes-snap-spanish.pdf | |||||
| IM-4HCB | Home and Community Based (HCB) Services | https://dssmanuals.mo.gov/wp-content/uploads/2020/05/home_community_based_services-im4.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/06/im-4hcbs-es.pdf | |||||
| IM-4Healthcare | Health Care Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/health-care-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/health-care-brochure-spanish.pdf | |||||
| IM-4Hearings | Hearings Information | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4-hearings.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4-hearings-spanish.pdf | |||||
| IM-4LIHEAP | Low Income Home Energy Assistance Program (LIHEAP) Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/liheap-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/liheap-brochure-spanish.pdf | |||||
| IM-4LIHEAP Flyer | Low-Income Home Energy Assistance Program (LIHEAP) Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/liheap-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/liheap-flyer-spanish.pdf | |||||
| IM-4MSP | Medicare Savings Program (MSP) Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4msp.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/06/im-4msp-es.pdf | |||||
| IM-4MHND | MO HealthNet Nondiscrimination Notice | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-4-MHN-Nondiscrimination-MHND.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-4-MHN-Nondiscrimination-MHND-Spanish.pdf | |||||
| IM-4MHN How To Use | How to use your MO HealthNet Benefit | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4mhn.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/im-4mhn-es.pdf | |||||
| IM-4MHN Report a Change | MO HealthNet Report a Change Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/reporting-changes-mhn.pdf | ||||||
| IM-4MLIS | IM-4 Multi-Language Interpreter Services | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-4-Multi-Language-Interpreter-Services-MLIS.pdf | ||||||
| IM-4MYDSS | myDSS Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/IM-4myDSS-Flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/10/im-4mydss-flyer-spanish.pdf | |||||
| IM-4NHC | MO HealthNet for Nursing Home Care - Regional Nursing Home Offices | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4nhc.pdf | ||||||
| IM-4PRM | MO HealthNet for Kids - CHIP Premium Chart | https://dssmanuals.mo.gov/wp-content/uploads/2019/05/7.1.19-IM-4PRM.pdf | ||||||
| RSB-1 | Rehabilitation Services for the Blind Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/rsb-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/rsb-brochure-spanish.pdf | |||||
| IM-4RSB Flyer | Rehabilitation Services for the Blind Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/rsb-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/rsb-flyer-spanish.pdf | |||||
| IM-4SkillUP | SkillUP Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/skillup-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/skillup-brochure-spanish.pdf | |||||
| IM-4SkillUP Flyer | SkillUP Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/skillup-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/skillup-flyer-spanish.pdf | |||||
| IM-4SMD | SNAP Medical Deductions for Elderly and Disabled Missourians Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-4smd.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-4smd-spanish.pdf | |||||
| IM-4SMHB | Show-Me Healthy Babies (SMHB) Program Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/smhb-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/10/smhb-flyer-spanish.pdf | |||||
| IM-4SNC | Supplemental Nursing Care (SNC) Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4-snc-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/06/im-4snc-es.pdf | |||||
| IM-4SPENDDOWN | Spend Down Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/spend-down-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/spend-down-flyer-spanish.pdf | |||||
| IM-4TA | Temporary Assistance Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/temporary-assistance-brochure.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/01/temporary-assistance-brochure-spanish.pdf | |||||
| IM-4TWHA | Ticket to Work Health Assurance Program (TWHA) Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/brochure_twha.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/10/brochure_twha_spanish.pdf | |||||
| IM-4TMH | Transitional MO HealthNet | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4tmh.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/10/im-4tmh-spanish.pdf | |||||
| IM-4Vendor Planning | MO HealthNet (Missouri Medicaid) Nursing Home Coverage Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-4vpf.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/06/im-4vpf-es.pdf | |||||
| MO HealthNet Annual Renewal Poster | https://dssmanuals.mo.gov/wp-content/uploads/2022/09/IM-4-Annual-Review.pdf | |||||||
| IM-6 | Authorization for Release of Information | https://dssmanuals.mo.gov/authorization-for-release-of-information/ | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-6.dotx | https://dssmanuals.mo.gov/wp-content/uploads/2021/07/im-6.pdf | ||||
| IM-6AR | Appointing an Authorized Representative | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-6ar-app.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-6AR_ES_signature.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/IM-6AR_LP_signature.pdf | ||||
| IM-6ARR | IM Authorized Representative Revocation | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/IM-6ARR-IM-Authorized-Representative-Revocation.pdf | ||||||
| IM-6NF | Authorization for Release of Medical/Health Information to Nursing Facilities, In-Home Nursing Care Providers, and Other Providers of Medical Services | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-6nf.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/IM-6NF_ESfillable.pdf | |||||
| IM-7 | Financial Information Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-7.dotx | ||||||
| IM-7A | Alternative Account Verification Form | https://dssmanuals.mo.gov/wp-content/uploads/2020/12/IM-7A.pdf | ||||||
| IM-9 | Insurance and Prepaid Burial Letter | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-9.dotx | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-9.pdf | |||||
| IM-10 | School Verification Report | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-10.dotx | ||||||
| IM-20 | Agreement for Direct Deposit | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-20.dotx | ||||||
| IM-29PA | Provider Attestation of Physician's Order of Medical Necessity | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-29pa.pdf | ||||||
| IM-29TE | MO HealthNet Spend Down Transportation Expense Log | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/im-29TE.docx | ||||||
| IM-31F | Applying for SNAP Benefits | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-31f.docx | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-31f-spanish.docx | |||||
| IM-31V | Allowed Verification Form | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/im-31v.pdf | ||||||
| IM-50AA | Information Notice - Regarding an Action Taken On Your Case - Accuity | https://dssmanuals.mo.gov/wp-content/uploads/2020/12/im-50aa-information-notice.pdf | ||||||
| IM-50AFGE | Information Notice - Regarding an Action Taken On Your Case - Accurint | https://dssmanuals.mo.gov/wp-content/uploads/2021/02/IM-50AFGE.pdf | ||||||
| IM-50E | Information Notice - Regarding an Action Taken On Your Case - Equifax | https://dssmanuals.mo.gov/wp-content/uploads/2021/03/IM-50E.pdf | ||||||
| IM-55A | Transitional MO HealthNet - First Quarterly Report | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55-abc-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55a.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55a-spanish.pdf | ||||
| IM-55B | Transitional MO HealthNet - Second Quarterly Report | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55-abc-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55b.docx | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55b-spanish.pdf | ||||
| IM-55C | Transitional MO HealthNet - Third Quarterly Report | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55-abc-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55c.docx | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-55c-spanish.pdf | ||||
| IM-60A | Medical Report Including Physician's Certification/Disability Evaluation | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-60a-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-60a.pdf | |||||
| FS-61 | SNAP (Food Stamps) Summary to Determine Fitness for Work | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/fs-61.pdf | ||||||
| IM-61B | Disability History | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-61b-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/06/im-61b.pdf | |||||
| IM-61C | Work History - Past 10 Years | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-61c-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/09/im-61c.pdf | |||||
| IM-61D | Provider History | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-61d-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/09/im-61d-provider-history.pdf | |||||
| IM-61D-OPTH | Ophthalmologist / Optometrist Information Request | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-61d-opth-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/08/IM-61D-OPTH.docx | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-61dlp-opth.pdf | ||||
| IM-61MRT | Medical Review Team Packet to Determine Disability | https://dssmanuals.mo.gov/wp-content/uploads/2021/09/im-61mrt.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/12/im-61mrt-sp.pdf | |||||
| IM-63PEME | Post Eligibility Medical Expense Budgeting Request | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-63-peme.docx | ||||||
| IM-64 | Request for Participant MO HealthNet Reimbursement | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/im-64-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-64.docx | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-64.pdf | ||||
| IM-68 | Visual Disability Examination Report | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-68.docx | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-68.pdf | |||||
| IM-70 | Good Faith Effort to Sell Declaration | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-70.pdf | ||||||
| IM-71 | Certification of Need for Psychiatric Services | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-71.pdf | ||||||
| IM-72FNIS | Facility Notification Information Sheet | https://dssmanuals.mo.gov/wp-content/uploads/2021/01/facility-notification-information-sheet.doc | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-72.pdf | |||||
| IM-78 | Declaration and Assessment of Assets | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-78-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-78.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-78-spanish.pdf | ||||
| IM-79 | Intent to Transfer Assets Agreement | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-79.dotx | ||||||
| IM-79A | Notification of Requirement to Transfer Assets | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/IM-79A.dotx | ||||||
| IM-80A | Waiver of 10-day Advance Notice | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-80a.pdf | ||||||
| IM-99 | Burial Fund Resource Designation | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-99.docx | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-99-spanish.pdf | |||||
| IM-103 | Electronic Benefits Transfer (EBT) Available Date for Food Stamps on the Regular Payroll | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-103.pdf | ||||||
| IM-110 | Replacement Request | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-110.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/09/im-110-es.pdf | |||||
| IM-114 | Voluntary Repayment Authorization Form | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-114.pdf | ||||||
| IM-145 | Change Report | https://dssmanuals.mo.gov/wp-content/uploads/2023/02/im_145.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/09/im-145-es.pdf | |||||
| IM-150 | Suspending Incarcerated Participants | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/IM-150-Suspending-MO-HealthNet-Participants-Form-fillable-date-fields.pdf | ||||||
| IM-151 | Inpatient Coverage for Incarcerated Participants | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-151.pdf | ||||||
| IM-152 | Restoring a Suspended Participant Change Report | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-152.pdf | ||||||
| IM-161A | Withdrawal of Waiver of Administrative Hearing Disqualification Consent Agreement | https://dssmanuals.mo.gov/wp-content/uploads/2023/01/IM-161a-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-161a.pdf | |||||
| IM-210 | Report of Food Stamp Quality Control Review | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-210-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/08/IM_210.pdf | |||||
| IM-214 | Affidavit for Replacement Check | https://dssmanuals.mo.gov/wp-content/uploads/2025/04/im-214-inst.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-214.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-214-spanish.pdf | ||||
| IM-215 | Affidavit of Forgery | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-215.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-215-spanish.pdf | |||||
| IM-311 | Missouri Employment and Training Program (METP) Referral and Response | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-311-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/im-311.pdf | |||||
| IM-366 | Drug Conviction Exception Determination Worksheet | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/im-366.pdf | ||||||
| CS-9 | Changing your support order | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/cs-9-changing-support-order.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2021/11/cs-9-changing-support-order-spanish.pdf | child support | ||||
| MO 886-4576 | Application for Financial Help to Heat or Cool Your Home (LIHEAP) | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-application.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-application-spanish.pdf | |||||
| MO 886-4657 | Qualified Income Trust (QIT) | https://dssmanuals.mo.gov/wp-content/uploads/2021/09/qit_instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/qit.pdf | |||||
| IM-100RWC | Request to Withdraw or Close | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/Request-to-withdraw-or-close-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/09/im-100rwc.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/request-withdraw-or-close-spanish.pdf | ||||
| TPL-1 | Third Party Resource Form | https://dssmanuals.mo.gov/wp-content/uploads/2020/10/tpl-1.pdf | ||||||
| LIHWAP Supplier Agreement | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/lihwap-supplier-agreement.pdf | |||||||
| WA-1LR | LIHWAP Landlord Documentation Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/lihwap-landlord-documentation-request.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/lihwap-landlord-doc-request-spanish.pdf | |||||
| MO 886-4698 | DCN Update Coversheet (for LIHEAP) | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/dcn_update_coversheet.pdf | ||||||
| MO 886-4461 | DSS Confidentiality | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/MO886-4461.pdf | ||||||
| MO 886-4697 | LIHEAP Online Access Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-online-access-request.pdf | ||||||
| LIHEAP-1B | Information Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-1b.pdf | ||||||
| LIHEAP-1C | Low Income Interview Guide | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-1c.pdf | ||||||
| LIHEAP-3 | Employee Wage Documentation Report | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-3.pdf | ||||||
| LIHEAP-8 | Energy Assistance Claims and Restitution | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/liheap-8.pdf | ||||||
| EA-1E | Energy Assistance Landlord/Renter Documentation Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/02/ea-1e.pdf | ||||||
| EA-12 | Supplier ACH/EFT Application - LIHEAP | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/supplier-ach-eft-application.pdf | ||||||
| LIHEAP Appendix K | LIHEAP Energy Assistance Refund | https://dssmanuals.mo.gov/wp-content/uploads/2022/03/liheap-energy-assistance-refund.pdf | ||||||
| MO 231-0167 | Missouri Voter Registration Application | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/voter-registration-application.pdf | ||||||
| IM-85 | Hearing Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/im-85-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/im-85.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2025/05/im-85-es.pdf | ||||
| IM-86 | Cancel Hearing Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/im-86-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/im-86.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2025/05/im-86-es.pdf | ||||
| IM-4Know Your Rights | SNAP Know Your Rights flyer | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/IM-4-Know-Your-Rights_flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/IM-4-Know-Your-Rights_flyer_Spanish.pdf | |||||
| IM-2SR | Signature Request Form | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/IM-2SR-Signature-Request-Form.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/05/IM-2SR-Signature-Request-Form_ES.pdf | |||||
| FSD-4 | Customer Service Form | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/fsd-4-instructions.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2020/09/fsd-4-customer-service.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/09/fsd-4-es.pdf | ||||
| IM-31B | Your Rights and Responsibilities as a Supplemental Nutrition Assistance Program (SNAP) Household | https://dssmanuals.mo.gov/wp-content/uploads/2022/07/im-31b.pdf | ||||||
| IM-1MSP | Application for Medicare Savings Programs | https://dssmanuals.mo.gov/wp-content/uploads/2022/08/im-1msp.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/08/im-1msp-spanish.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/08/im-1msp-lp.pdf | ||||
| IM-365P | Emergency MO HealthNet Care for Ineligible Aliens (EMCIA) Provider Request | https://dssmanuals.mo.gov/wp-content/uploads/2022/08/im-365p.pdf | ||||||
| LIHEAP/LIHWAP Postcard | Need Help with Utility Costs? | https://dssmanuals.mo.gov/wp-content/uploads/2022/10/liheap-lihwap-postcard.pdf | ||||||
| myDSS Business Card | https://dssmanuals.mo.gov/wp-content/uploads/2022/11/myDSS-Business-Card_v5-1.pdf | IM-4 | ||||||
| IM-153 | Applying for Incarcerated Participants in Department of Corrections | https://dssmanuals.mo.gov/wp-content/uploads/2022/11/im-153.pdf | ||||||
| IM-583SO | School Outreach Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/school-outreach-flyer-mhk.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/school-outreach-flyer-mhk-spanish.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2022/04/school-outreach-spreadsheet-mhk.xlsx | MO HealthNet for Kids | |||
| IM-583CCO | Childcare Outreach Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/instructions-for-lc-providers-on-outreach.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/SB-583-mhn-for-kids-child-care-provider-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2024/03/sb-583-mhn-for-kids-child-care-provider-flyer-es.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/facility-child-care-provider-outreach-applications-tracker.xlsx | Facility, MO HealthNet for Kids, spreadsheet | ||
| IM-4SkillUP/ABAWD | SkillUP/ABAWD Mailer | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/skillup-abawd-mailer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/skillup-abawd-mailer-spanish.pdf | Able-Bodied Adults Without Dependents | ||||
| IM-4MWA Flyer | Employment & Training Support for Temporary Assistance Participants | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/mwa-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/04/mwa-flyer-spanish.pdf | |||||
| IM-4BPIL Chart | Benefit Program Income Limits | https://mydss.mo.gov/media/pdf/benefit-program-limit-chart | ||||||
| IM-111 | Electronically Stolen Benefit Replacement Request | https://dssmanuals.mo.gov/wp-content/uploads/2023/09/im-111.pdf | ||||||
| IM-4Supporting Through Change | Supporting Children & Families Through Change Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2023/10/supporting_through_change_flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/10/supporting_through_change_flyer_spanish.pdf | |||||
| IM-4UPLOAD | FSD Document Upload Portal Flyer | https://dssmanuals.mo.gov/wp-content/uploads/2023/11/im-4-upload-documents-flyer.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2023/11/im-4-upload-documents-flyer-es.pdf | |||||
| IM-63HWR | MO HealthNet Undue Hardship Waiver Request | https://dssmanuals.mo.gov/wp-content/uploads/2024/01/im-63-hwr.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2024/01/im-63-hwr-es.pdf | |||||
| MO 886-4560 | Consumer's Authorization for Disclosure of Confidential Information | https://dssmanuals.mo.gov/wp-content/uploads/2024/02/mo886-4560.docx | child support, fatherhood, outreach, css, consumers | |||||
| MOSB-1 | Application for Missouri SuN Bucks | https://dssmanuals.mo.gov/wp-content/uploads/2024/08/mosb-1.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2024/08/mosb-1-es.pdf | |||||
| IM-4Employment Services | Employment First Brochure | https://dssmanuals.mo.gov/wp-content/uploads/2024/11/im-4-employment-services.pdf | https://dssmanuals.mo.gov/wp-content/uploads/2024/11/im-4-employment-services-es.pdf | |||||
| IM-29PROV | MO HealthNet Spend Down Provider | https://dssmanuals.mo.gov/wp-content/uploads/2025/02/im-29prov.pdf | ||||||
| IM-29SDP | MO HealthNet Spend Down Participant | https://dssmanuals.mo.gov/wp-content/uploads/2025/02/im-29sdp.pdf | ||||||
| IM-369 | Substance Abuse Treatment Programs Drug Conviction Exception Verification Form | https://dssmanuals.mo.gov/wp-content/uploads/2025/05/im-369.pdf |