Fa402 Form – Fill Out and Use This PDF

Fa402 Form – Fill Out and Use This PDF

Fa402 Form PDF Details

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Fa402 Form PDF Details

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Fa402 Form PDF Details

If you are a U.S. Citizen or Permanent Resident, and you plan to live outside of the United States for more than one year, you must file Form Fa402 with the nearest U.S. Embassy or Consulate. The form is used to notify the U.S. Government of your upcoming absence and to maintain your visa status while abroad. Failing to file Form Fa402 could result in loss of lawful permanent resident status or denial of re-entry into the United States upon your return. For more information on filing Form Fa402, visit our website today.

Question	Answer
Form Name	Fa402 Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	mo healthnet forms print, missouri medicaid recertification form, mo healthnet forms, form mo review form

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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.

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
(First, Middle, Last)	(Maiden)

(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

If Yes, who: __________________________

If you indicated that you are blind:

1. Do you have a sighted spouse?

Yes

2. Do you solicit alms?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

CASH AND SECURITIES – PERSONAL PROPERTY

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

YES

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

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

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

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

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)

How to Edit Fa402 Form Online for Free

With the help of the online PDF tool by FormsPal, it is possible to fill in or change form mo review form right here. Our tool is constantly developing to present the best user experience achievable, and that is due to our dedication to continuous improvement and listening closely to testimonials. This is what you'd need to do to begin:

Step 1: Firstly, open the pdf editor by clicking the "Get Form Button" at the top of this page.

Step 2: After you access the editor, you'll see the document ready to be filled in. Aside from filling in various blank fields, you could also perform other actions with the file, specifically putting on any text, editing the original textual content, adding images, affixing your signature to the PDF, and more.

Pay attention while filling in this pdf. Make sure all necessary fields are done correctly.

1. Start filling out the form mo review form with a selection of necessary blank fields. Note all of the necessary information and ensure not a single thing missed!

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

4. Filling out Are you living in or supported by, LOCATION, VALUE, DEBT, m Household furniture in use n, MAKE, YEAR, OWNER, LICENSED, VALUE, DEBT, HOW USED, t Vehicles include recreational, and Page of is essential in the fourth part - don't forget to take the time and be mindful with every field!

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

5. Last of all, this final subsection is precisely what you should complete before using the document. The blanks in this case include the next: MO HEALTHNET ELIGIBILITY REVIEW, Yes, DCN, LIST KIND AND LOCATION WHO HOLDS, MORTGAGE, LOAN, NUMBER, WHOSE NAME IS ON THE DEED, CURRENT, VALUE, AMOUNT OWED, EQUITY, HOW IS IT, USED, and TRANSFER OF PROP TRANSFER OF.

Completing part 5 of mo health net division of assets form

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Head of Eligibility Unit

Street Address

Current Phone

Work or Message Phone

Load Number