Fa402 Form PDF Details

The importance of the FA402 form in the context of MO HealthNet cannot be understated. Yearly, individuals receiving or applying for MO HealthNet coverage are mandated to undergo an eligibility review, a process encapsulated within this form. Its comprehensive nature demands accurate and complete information regarding household income, employment status, resources like bank statements and property, changes in household dynamics, and health insurance details, among others. What is distinctive about the FA402 form is its dual focus on verification and integrity; it not only gathers data necessary for assessing eligibility but also stands as a legal document where applicants attest to the truthfulness of their information under penalty of perjury. Specifically, it requires details on changes in citizenship or immigration status, any disabilities within the household, and even questions aimed at understanding the resident's intent regarding their stay in Missouri and plans for entering healthcare facilities. Additionally, this form serves as a gateway for voter registration, subtly encouraging civic participation among applicants. The procedural aspect includes instructions for completing the form, implications of non-compliance, and resources for assistance, ensuring that applicants are well-guided through the process. Thus, the FA402 form embodies a crucial intersection of healthcare access and legal accountability within Missouri's support system.

QuestionAnswer
Form NameFa402 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesmo healthnet forms print, missouri medicaid recertification form, mo healthnet forms, form mo review form

Form Preview Example

MO HEALTHNET ELIGIBILITY REVIEW INFORMATION

We are required to complete an annual review of MO HealthNet eligibility. In order to determine continued eligibility, we are asking you to complete all questions on this form. Race and ethnic group information is only for statistical use and is optional. The Social Security Number is required only for persons who are receiving or applying for MO HealthNet coverage.

After you have completed the form, please sign on the line indicated “Signature/Affidavit/Mark”. Return this form to the return address above or to any local Family Support Division facility by *** ____________***.

If employed, please include proof of your household income such as a month of your most recent paycheck stubs, letter from your employer, or copies of your latest tax return if self-employed.

Verification of resources such as bank statements, quarterly statements for retirement accounts or written statements from financial institutions is required. These documents will be returned to you at your request.

Failure to return this form may result in MO HealthNet coverage being canceled. Contact the Family Support Division Information Center at 855-373-4636 if you have any questions.

Do you want to register to vote? If so, just fill out the voter registration form included with the review form and return it to any local Family Support office or with this form. If you don’t fill out the form, MO HealthNet coverage will not be affected.

Instructions: Please read each item carefully before you answer it. The answers you give will be used to determine continued eligibility for MO HealthNet. If you need assistance in completing the form, or have any questions, please contact the Family Support Division Contact Center. You must answer each question accurately and completely in ink. You may be required to provide verification of your statements. Attach an additional sheet or use the “Additional Information” section if more space is needed for any section.

Head of Eligibility Unit

 

Supercase

 

DCN

 

 

 

 

 

 

 

 

Street Address

 

City

 

 

State

Zip

 

 

 

 

 

 

Current Phone

Work or Message Phone

Load Number

 

 

 

 

 

 

 

 

Below, list your name first, then list all other persons who live with you.

Name

 

Hispanic

Race*/

Relationship to

Birthdate

Social Security

(First, Middle, Last)

(Maiden)

Y/N

Sex

YOU

 

Number

 

 

 

 

 

(self)

*1 Caucasian 2 Black/African American 4 American Indian/Alaska Native 5 Asian 6 Native Hawaiian/Pacific Islander

Do you or your spouse if married, reside in or plan to enter a Nursing or Residential Care Facility? If Yes, who: _________________________________________

Where:_____________________________________________

When: __________________

 

 

 

I/We are residents of Missouri and intend to remain in Missouri.

Yes

No

Has there been any change in citizenship or immigration status for individuals currently in your household and receiving MO

HealthNet?

Yes

No If Yes, list the individual whose status has changed with the current information in the blanks.

Name

 

 

Immigration Status

Registration Number

Date of Entry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 6

FA402 (05-14)

 

MO HEALTHNET ELIGIBILITY REVIEW FORM

 

 

 

 

 

 

 

DCN:

 

 

 

Is anyone in the household blind or disabled?

Yes

No

If Yes, who: __________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you indicated that you are blind:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Do you have a sighted spouse?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Do you solicit alms?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Have you had eye surgery since the last review or application?

Yes

No

 

 

 

 

 

 

 

 

4. If you are under the age of 75, are you willing to have medical treatment or an operation to correct blindness?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. If recommended, are you willing to accept vocational training or work at an occupation for which you are suited?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Are you living in or supported by a public, medical or private institution?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASH AND SECURITIES – PERSONAL PROPERTY

 

 

 

 

 

 

 

 

 

 

 

 

I/We have the following cash, securities, or personal

 

YES

NO

IN WHOSE NAME

 

LOCATION

 

 

VALUE

 

property.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Checking account/joint checking accounts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account numbers:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Savings accounts, joint savings accounts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account numbers:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Patient accounts at a nursing home or other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

institution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Savings or cash at home, on my person, or being

 

 

 

 

 

 

 

 

 

 

 

 

 

 

held by someone else

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Stocks, bonds, or other investments. If yes, how

 

 

 

 

 

 

 

 

 

 

 

 

 

 

many?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Notes or mortgages owed to you/Promissory notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Trust funds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Annuity policies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i. Certificates of Deposit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j. Retirement funds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

k. Property in Probate Court

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l. Property held in Safe Deposit box (State location and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contents of box)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION

 

 

 

VALUE

 

 

DEBT

 

m. Household furniture (in use)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n. Household furniture (not in use)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o. House trailer (Mobile home)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p. Jewelry (other than wedding and engagement rings,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

watches or costume jewelry)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q. Business equipment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

r. Livestock, grain, produce, farm equipment, tools, etc

 

 

 

 

 

 

 

 

 

 

 

 

 

 

s. other (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

t. Vehicles (include

 

MAKE

 

 

YEAR

 

OWNER

LICENSED

 

VALUE

 

DEBT

 

HOW USED

 

recreational and watercraft)

 

 

 

 

 

 

 

 

 

Y/N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 6

 

 

 

 

 

 

FA402 (05-14)

 

MO HEALTHNET ELIGIBILITY REVIEW FORM

 

 

 

 

DCN:

 

 

REAL PROPERTY

 

 

 

 

 

 

 

 

 

 

 

 

I/We own or are buying real estate.

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST KIND AND LOCATION

WHO HOLDS THE

 

LOAN

 

WHOSE NAME IS

CURRENT

AMOUNT

 

EQUITY

HOW IS IT

 

 

 

MORTGAGE?

 

NUMBER

 

ON THE DEED?

VALUE

OWED

 

 

USED?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSFER OF PROPERTY OR RESOURCES

 

 

 

 

 

 

 

 

 

 

Has anyone in your home sold or given away any money, vehicles property or other resources?

 

Yes

No

 

If yes, complete the following:

 

 

 

 

 

 

 

 

 

 

 

 

What?

__________________________________________________________________________________________

 

When?

__________________________________________________________________________________________

To Whom? __________________________________________________________________________________________

Why

_____________________________________________________________Amount received $ ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIFE INSURANCE

 

 

 

Does anyone in your home own a life insurance policy?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST PERSON INSURED

NAME OF COMPANY

 

POLICY NUMBER

FACE VALUE

 

PAID BY WHOM

 

DATE

 

IRREVOCABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURCHASED

 

Y/N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH INSURANCE (other than MO HealthNet):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I/We have medical insurance.

Yes

 

No If Yes, complete the following:

 

 

 

Name of Insured

 

Name of Company

Policy

Policy

 

 

 

Coverage Type

 

Number

Holder

 

(Doctor or Hospital) If limited, explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCOME

Please include proof of your income such as paycheck stubs for the last 30 days, letter from your employer, copies of your latest tax return if self employed, or award letter for Social Security or pensions. At your request these documents will be returned to you.

Is anyone in your household employed?

Yes

No

If Yes, complete the following and attach verification:

 

 

 

 

 

 

 

 

 

 

 

NAME

EMPLOYER

EMPLOYER

 

PAY

PER*

CHECK

DATE

GROSS

TIPS,

 

NAME

PHONE

 

RATE

 

DATE

REC’D

INCOME

ETC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Hour Day

Week

Every two weeks

Twice monthly Month

 

 

 

 

Does anyone in your household operate his/her own business or are otherwise self-employed?

Yes No

 

If Yes, who: _____________________________. If Yes, complete below and attach verification.

 

 

 

 

Describe the type of self-employment (babysitting, farm income, other) _____________________________.

 

Enter amount earned ____________ Per *

Hour

Day

Week

Every two weeks

Twice monthly

Month

 

 

 

 

 

Do you anticipate any changes in employers, hours worked or wages paid?

Yes

No

 

 

If Yes explain: ______________________________________________________________________________

 

 

 

 

 

Is there anyone who plans to go to work?

Yes

No If Yes, who: ________________________________

 

Where: __________________________________ When: __________________________________________

 

 

 

 

 

 

 

 

 

 

Page 3 of 6

 

 

 

FA402 (05-14)

MO HEALTHNET ELIGIBILITY REVIEW FORM

DCN:

Do you or any other household member receive money from any of the following sources?

 

Yes

NO

Amount

 

 

Yes

No

Amount

Social Security

 

 

 

 

 

Union Funds or Pension Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income (SSI)

 

 

 

 

 

Insurance Settlements

 

 

 

 

 

 

 

 

 

 

 

 

 

Alimony

 

 

 

 

 

VA Aid and Attendance

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support payments

 

 

 

 

 

Armed Forces Allotment

 

 

 

 

 

 

 

 

 

 

 

 

 

Money from others (friends, relatives, etc)

 

 

 

 

 

Room and/or Board Received

 

 

 

 

 

 

 

 

 

 

 

 

 

Veteran’s Benefits

 

 

 

 

 

Money from Sale of Property

 

 

 

 

 

 

 

 

 

 

 

 

 

Worker’s Compensation

 

 

 

 

 

Interest from Savings/Checking

 

 

 

 

 

 

 

 

 

Account

 

 

 

Unemployment Compensation

 

 

 

 

 

Income received from Trusts

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability or Sick Benefits

 

 

 

 

 

Income received from Annuities

 

 

 

 

 

 

 

 

 

 

 

 

 

Income from Training Program

 

 

 

 

 

Rent received from

 

 

 

 

 

 

 

 

 

Land/Buildings

 

 

 

Any other income

 

 

 

 

 

 

 

 

 

Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has anyone recently applied for any of the above benefits?

Yes

No

If Yes, explain: _____________________________________________________________________________

COLLATERAL INFORMATION

Please provide the names of two persons who live outside of your home and are not related to you, who can verify your statements.

Name

Name

 

 

Address

Address

 

 

Telephone Number

Telephone Number

 

 

This person is able to verify my statements because:

This person is able to verify my statements because:

 

 

ADDITIONAL INFORMATION: (If additional room is needed for any question please enter information here and attach verification as requested) __________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Page 4 of 6

FA402 (05-14)

MO HEALTHNET ELIGIBILITY REVIEW FORM

DCN:

PLEASE READ CAREFULLY AND SIGN BELOW:

I, (We), further authorize the Department of Social Services, through the Director of Family Support or his appointee, to make an investigation of these circumstances and statements.

I, (We), will provide Social Security Numbers (SSN) of all persons applying for or receiving public assistance. It is a condition of eligibility except for Blind Pension. The SSN will be used to determine eligibility level of benefits, verify information, prevent duplicate participation and facilitate mass changes in Federal benefits (Section 1137 of the Social Security Act). Included in the agencies contacted for income and eligibility information are the Social Security Administration, the Internal Revenue Service, and the Missouri Division of Employment Security. Some of the information may be obtained by computer match.

I, (We), will notify the Department of Social Services promptly of any changes in income, expenses, property holdings, financial conditions, household composition, and any change in address.

This is to certify under penalty of perjury that the forgoing information is true, accurate, and complete. I, (We), understand that any false claims, statements, or documents, or concealment of any material fact, may be prosecuted under applicable laws of the State of Missouri and/or the United States.

It is a crime, and upon conviction, punishable by imprisonment by the Missouri Division of Corrections for a period not to exceed five years; or by confinement in the county jail for a period not to exceed one year; or by fine not to exceed one thousand dollars; or by both, where an act or series of acts a person defrauds the state of one hundred fifty dollars or more, or a misdemeanor if the amount is less than one hundred fifty ($150) dollars.

When the person applies to receive monetary payments, hospital, medical, dental, or pharmaceutical service or commodity provided pursuant to provisions of chapter 208 or 209 RSMo and the person shall knowingly: (a) make, or (b) cause to be made, or (c) aids or abets another in the making of any false statements or misrepresentation of any fact required to be reported either by law or by rule or regulation of this state or of the United States in applying for public assistance or any fact used in the determination of any person’s initial or continued eligibility for any public assistance with the intent to secure public assistance when not entitled to public assistance or with intent to secure more public assistance benefits than the person is entitled to. The same penalties apply to any person who knowingly (a) conceals or (b) knowingly fails to report or (c) knowingly causes the concealment or failure to report or (d) knowingly aids or abets another in the concealment or failure to report any fact or event required to be reported in applying for or used in the determination of any persons initial or continued eligibility for public assistance or food stamps or to secure public assistance or food stamps in an amount greater than entitled to receive.

ATTENTION: Federal regulations require that the Missouri Department of Social Services (DSS) maintain a publicly available "Notice of Privacy Practices" that describes our policy for handling protected health information. The department has implemented a privacy policy and prepared a Notice of Privacy Practices. You may obtain a copy of this notice on the DSS Web site at http://www.dss.mo.gov/hipaa/hprivacy.pdf or from any county DSS office

My signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete to the best of my knowledge.

Signature/Affidavit/Mark

Date

Signature/Affidavit/Mark

Date

Page 5of 6

FA402 (05-14)

MO HEALTHNET ELIGIBILITY REVIEW FORM

DCN:

You may contact the Family Support Division by calling the FSD Information Center toll free Monday thru Friday

7am – 6pm at 1-855-373-4636 (1-855-FSD-INFO).

You may also call the Family Support Division Automated Line available 24 hours, 7 days a week at

1-800-392-1261.

Page 6of 6

FA402 (05-14)

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The way to fill in mo health net division of assets form portion 1

2. Soon after the first section is completed, proceed to type in the relevant information in these: First Middle Last Maiden, Sex, YOU self, Number, Caucasian BlackAfrican American, Registration Number, Immigration Status, Date of Entry, Yes, Yes, and Page of.

Completing section 2 in mo health net division of assets form

Lots of people generally get some things incorrect while filling in Yes in this part. Don't forget to revise whatever you type in right here.

3. Completing MO HEALTHNET ELIGIBILITY REVIEW, Yes Yes, No No, Yes, No If Yes who, DCN, If you are under the age of are, Yes, If recommended are you willing to, Yes, Yes, IN WHOSE NAME, YES, Are you living in or supported by, and LOCATION is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part number 3 for completing mo health net division of assets form

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Filling out part 4 of mo health net division of assets form

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Completing part 5 of mo health net division of assets form

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