MRT Packet

The Family Support Division uses the below documents in order to make a disability determination for clients who do not actively receive Social Security Disability or SSI.

The following forms are required to complete the MO HealthNet for Disabled application:

 

IM-61B - Disability Questionnaire

  • Fill in the client's answers to all the questions
  • Leave the pertinent information and observations of the Eligibility Specialist section blank.

IM-61C - Work History

  • The form asks for the past 10 years of work history.
  • Complete the form based on information readily available to the individual, do not delay submitting the form trying to get exact information.
  • If the individual doesn’t remember specific information such as phone numbers, addresses, monthly income, etc. just put an approximation based on what is remembered.
  • Reason for leaving and job duties are important if the reason for it or the inability to perform the job duties are related to the individual’s medical condition.

IM-61D - Doctor/Medical Facility List

  • The form asks the individual to list all hospitals, medical facilities, and physicians from whom he or she has received medical care in the past 12 months.
  • Mental health professionals, such as psychologists, advance practice nurses, and licensed clinical social workers should also be included.

MO 650-2616 - Authorization for Disclosure of Consumer Medical/Health Information

  • There are two signatures required on this form:
    • Page 2, the client should sign the line under question #2.
    • Page 2, where it says Signature of Consumer under the line "My signature below acknowledges that I have read, understand, and authorize the release of my PHI.