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