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

Apply for Medicare Savings Programs

INSTRUCTIONS

INSTRUCTIONS: Read and answer each question completely and accurately. Attach additional pages as needed. 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.

Sign, date and return the application to FSD by:

  • Uploading your application: Visit mydssupload.mo.gov to upload a copy of your completed application
  • Mail to: Family Support Division, PO BOX 2700, Jefferson City, MO 65102
  • Fax to: 573-526-9400

NOTE: This is NOT an application for Healthcare. If you want to apply for MO HealthNet or other assistance programs, go to My DSS MO 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 taxes). 

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

OTHER INCOME

Other income may include:

Supplemental Security Income (SSI)

Social Security

Alimony

Veteran's Benefits

Pension/Retirement

Disability

Annuities

Assistance from friends or relatives

Unemployment Compensation

Trust Funds

Interest/Dividends
/Investments

Any other income not from a
job or self-employment

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

Resources - List all resources 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.

Resources - List all resources 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.

Resources - List all resources 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.

Resources - List all resources 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.

Resources - List all resources 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

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, call 855-373-4636, or visit any FSD Resource Center 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.

 

Automated Messages

You will receive messages related to your application or ongoing case(s) and information from MO FSD about general programs and services. If you opt-in to messaging while applying and later need help or want to opt-out, you can do that anytime you receive a message by replying HELP for help or STOP to cancel. Your decision to opt-in or opt-out of messages will not affect your eligibility for benefits. You recognize messages might include protected health information (PHI), such as your participation in the MO HealthNet program. Any PHI contained in our SMS text messages, emails and/or automated phone messages to you will be unencrypted and could be accessed by someone else. If your contact information changes, it is your responsibility to update FSD because failure to update may result in the disclosure of your PHI to others. You acknowledge you would like to sign up to receive personalized SMS text messages, emails and/or automated phone messages about your MO FSD case at the phone number(s) and/or email provided. Please note: Message frequency varies. Message and data rates may apply. By agreeing to receive communications from MO FSD, you acknowledge you understand and have read and agree to MO FSD Terms of Service and MO FSD Mobile Communications Privacy Policy at https://mydss.mo.gov/fsd-mobile-comms-privacy-policy.

 

I want to (check all that apply):

PLEASE READ CAREFULLY AND SIGN BELOW

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 My DSS MO 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