Application For Kids, Pregnant Women, And Parents (Page 2 of 4) in pdf

OTHER IMPORTANT INFORMATION ABOUT MO HEALTHNET

If you have questions or need assistance completing the application, call toll-free 1-888-275-5908.

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 mail 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.

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).

If possible, send this verification with your application. We will accept copies of these items, however, if

you send originals, we will copy them and return the originals with your notification letter. 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.

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 keep this page. It contains important information.

IM-1UA (01-08)

MO 886-2726 (01-08)

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