Application For Kids, Pregnant Women, And Parents printable pdf download

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APPLICATION FOR KIDS, PREGNANT WOMEN, AND PARENTS

MO HealthNet Service Center

525 Jules St. #127

St. Joseph, MO 64501

This application is for MO HealthNet for children under the age of 19, some parents, and pregnant

women. To apply, complete and sign the attached application and return it to the above address or your

local Family Support Division office.

INSTRUCTIONS FOR COMPLETING THE MO HEALTHNET APPLICATION

Section A - 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.

Section B - Household Information

List all the children, parents, step-parents or guardians in the household, yourself first. 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. Put an “X” in the last box to indicate you are applying for

MO HealthNet for that person.

Section C - Income

In order to determine your family’s eligibility for MO HealthNet, please complete this section. Attach a sheet

if more space is needed. Please submit income verification, for the last 30 days, with the application.

Section D - Insurance

For some applicants, eligibility for MO HealthNet will depend on their access to health insurance. It is

important that you complete this section. List all health insurance, regardless of source.

Section E - Absent Parent

Only complete this section if a parent of one of the children applying for MO HealthNet is absent from the

home. The law requires cooperation with Child Support Enforcement in obtaining payment for medical

care. 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, check “yes” in Question #1. 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.

If you claim “good cause”, by checking “yes” in Question #1 for not cooperating in obtaining medical

support, 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.

Section F - Signature

Please read this section carefully and sign the form. The effective date of MO HealthNet coverage is

based on the date your signed application is received.

Call 1-888-275-5908 if you have questions

Please keep this page. It contains important information.

MO 886-2726 (01-08)

IM-1UA (01-08)

Application For Kids, Pregnant Women, And Parents

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