1. Adaptive Form Title
  2. Main Panel
  3. Thank You

Apply for Medicare Savings Programs

INSTRUCTIONS: Read and answer each question completely and accurately. You can attach additional supporting documents or pages before submitting the application. If you are unable to complete this application, you may have someone else help you. If you have questions, contact Family Support Division (FSD) toll free at 855-373-4636.

NOTE: This is NOT an application for Healthcare. If you want to apply for MO HealthNet or other assistance programs, go to http://mydss.mo.gov/ and select Apply for Services or visit an FSD office to request an application. To apply by phone for MO HealthNet only call 855-373-9994.

APPLICANT NAME (FIRST, MIDDLE, LAST)

HOME ADDRESS (STREET ADDRESS, CITY, STATE, ZIP CODE)

MAILING ADDRESS (IF DIFFERENT THAN ABOVE)

COMPLETE THE FOLLOWING INFORMATION FOR YOU
COMPLETE THE FOLLOWING INFORMATION FOR YOUR SPOUSE (IF MARRIED)
MEDICARE/CITIZENSHIP

If no, list the following information for applicants named above who are not US citizens: Name, immigration status, registration number, and date of entry:

Click the (+) to add more fields. Click the (-) to remove added fields.

EMPLOYED

Click the (+) to add more fields. Click the (-) to remove added fields.

SELF-EMPLOYED

If yes, list who, describe what type of self-employment (babysitting, farm income, etc.), and amount earned (after expenses). 

Click the (+) to add more fields. Click the (-) to remove added fields.

OTHER INCOME

Other income may include:

Social Security

Pensions/Retirement

Disability

Annuities

Supplemental Security Income (SSI)

Unemployment Compensation

Interest/Dividends/Investments

Veteran's Benefits

Trust Funds

Alimony

Assistance from friends or relatives

Any other income not from a job or self-employment

Click the (+) to add more fields. Click the (-) to remove added fields.

ASSETS - List all assets owned by you or your spouse.

CASH AND ACCOUNTS - Include all checking accounts, savings accounts, certificates of deposit, annuities, cash on hand, stocks, bonds or other investments, notes or mortgages owed to you, property held in safe deposit boxes or any other resources.

Click the (+) to add more fields. Click the (-) to remove added fields.

ASSETS - List all assets owned by you or your spouse.

PERSONAL PROPERTY - Include burial lots, business or farm equipment, jewelry (other than wedding and engagement rings, watches or costume jewelry), property claims in probate court, or other personal property.

Click the (+) to add more fields. Click the (-) to remove added fields.

ASSETS - List all assets owned by you or your spouse.

VEHICLES - Include cars, trucks, vans, motorcycles, recreational vehicles, and any other vehicles.

Click the (+) to add more fields. Click the (-) to remove added fields.

ASSETS - List all assets owned by you or your spouse.

REAL ESTATE - Include any homes, buildings, land, or other real estate you or your spouse own or are buying.

Click the (+) to add more fields. Click the (-) to remove added fields.

ASSETS - List all assets owned by you or your spouse.

LIFE INSURANCE AND/OR BURIAL PLANS - Include any life insurance policies that you or your spouse are a policy owner.

Click the (+) to add more fields. Click the (-) to remove added fields.

OTHER HEALTH INSURANCE

If yes, complete the following:

Click the (+) to add more fields. Click the (-) to remove added fields.

PLEASE READ CAREFULLY AND SIGN BELOW

I/We UNDERSTAND that:

  • I/We are entitled to fair and equal treatment regardless of race, color, national origin, sex, age, religion, disability, ancestry, genetic information, pregnancy, sexual orientation, or veteran status.
  • If I/We disagree with the decision concerning our eligibility, I/we may request a fair hearing by contacting the FSD at myDSS.mo.gov, by phone, mail, or in person. This request must be received within 90 days of the eligibility decision.
  • I/We must provide Social Security Numbers (SSN) of all persons applying for MO HealthNet. The SSN is used to determine eligibility and verify information (Section 1137 of the Social Security Act).
  • I/We authorize the Director of FSD or his/her appointee to investigate and verify these circumstances and statements.
  • I/We must report any changes in circumstances within ten days of when they happen. Visit myDSS.mo.gov or call 855-373-4636 to report changes.
  • It is against the law to obtain or attempt to obtain benefits to which I/we are not entitled. Any false claim, statement or concealment of any material fact whatever, in whole or in part, may subject me to criminal and/or civil prosecution.
  • I/We must provide complete information regarding any health or accident insurance benefit available to any household member and I/we must report within 30 days any accident for which medical care is received.
  • I/We hereby authorize all providers of medical benefits who render services or merchandise to me/us under MO HealthNet to release all records regarding such services or merchandise to the Department of Social Services and its representatives.
  • An application for and acceptance of MO HealthNet constitutes an assignment of rights to the Department of Social Services, MO HealthNet Division for payment for medical care from a third party.
  • Provided I/we are found to be eligible for assistance, I/we wish payments by the MO HealthNet Division and/or the Title XVIII medical insurance program to be made directly to physicians and medical suppliers on any future covered unpaid bills for medical and other health services furnished me/us while eligible for MOHealthNet.
  • By signing this application, you are giving us permission to deliver, or cause to be delivered, automated phone calls and text messages regarding your case at the primary phone number you provided on page 2. You do not have to consent to this as a condition of eligibility.

 

If you want to opt out of getting these calls or messages, check here:

My/our signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete.

    Thank You

    Dear {formsubmittinguser},

    Thank you for submitting your Application for Medicare Savings Programs. You will be notified when we have completed your application. Family Support Division (FSD) may contact you if additional information is needed to process your application.

    NOTE: This is NOT an application for Healthcare. If you want to apply for MO HealthNet or other assistance programs, go to http://mydss.mo.gov/ and select Apply for Services or visit an FSD office to request an application. To apply by phone for MO HealthNet only call 855-373-9994.

    If you have any questions about your pending Application for Medicare Savings Programs, please call the FSD Customer Service Center at 855-373-4636. Your document number is {formuniqueid}.

    If you would like to print or save a copy of your Application for Medicare Savings Programs for your files, click the Print button below. If you decide to print or save, keep in mind that your document has private and personal information on it.

    Sincerely,

    Family Support Division