1. Adaptive Form Title
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3. Thank You

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• Thank You

 MO HealthNet Spend Down Provider

Provider Instructions: Please fill out this form when you have a patient who has qualified for spend down, and an actual bill is not yet available. By completing this form, you (or an authorized employee) are verifying that your patient has incurred, and personally owes payment for medical expenses you provided.

Patient First Name:

Patient Middle Name:

Patient Last Name:

MO HealthNet Number:

Provider Name:

Does the patient have Medicare or other Third-Party Insurance?

Yes

No

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Date of Service

Type of Service

Total Charge

Third Party Payment

Write-Off / Adjustment

Patient Responsibility

+

-

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Verify: By completing and signing this document, you verify that you have provided accurate information and that you will bill the patient for the amount due. Also, if you filled in the “total patient is responsible to pay” column with a good faith estimate, CHECK HERE

AUTHORIZED EMPLOYEE COMPLETING FORM

Name

Phone Number

Date

Date For Thank You Page HIDDEN

CAPTCHA

Submit

 

Dear {Authorized Employee - Name} at {Provider Name},

Your document was submited, {Date Submitted}. The document tracking number is {Form ID}.

The patient will be notified that an expense was submitted and if it is applied to their Spend Down liability.

Thanks!

Family Support Division

 

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Form ID