Every year, businesses and individuals throughout the United States are required to file various tax forms with the Internal Revenue Service (IRS). One such form is Form 886 3977, which is used to report transactions between related parties. This form is relatively complex, so it's important to understand exactly what it is used for and how to complete it. In this blog post, we will provide a comprehensive overview of Form 886 3977 and explain how to submit it correctly. We hope you find this information helpful!
| Question | Answer |
|---|---|
| Form Name | Form Mo 886 3977 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | im1bc_0901 bcct missouri provider form |
MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF FAMILY SERVICES
BCCT MEDICAL ASSISTANCE APPLICATION
BCCCP PROVIDER
TELEPHONE NUMBER
DIAGNOSIS DATE
FOR OFFICE USE ONLY
DATE APPLIED
DCN
SERVICE REP |
SUPERVISOR |
LOAD |
COMPLETE IN INK
A. MAILING ADDRESS
NAME (FIRST, MIDDLE, LAST)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
RACE/ETHNIC
ADDRESS (HOUSE NO., STREET, RURAL ROUTE, PO BOX NO) CITY, STATE, ZIP CODE COUNTY
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
MESSAGE PHONE NUMBER
B. INSTRUCTIONS: Please answer each question completely.
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YES |
NO |
1. Are you a U.S. citizen? If “NO”, list immigration status and registration number, date of entry: |
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2. Do you currently have healthcare insurance? |
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NAME OF COMPANY AND POLICY NUMBER |
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TYPE OF COVERAGE |
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DOCTOR |
HOSPITAL If limited coverage explain: |
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3.Do you have children under the age of 19 residing in your home?
4.Are you pregnant?
5.Are you blind?
6.Are you disabled?
C. PLEASE READ CAREFULLY AND SIGN BELOW:
YES
NO
•I agree to provide Social Security Numbers of all persons applying for Medicaid as required by law. The social security number is used to determine eligibility and verify information.
•I agree that my statements and information provided may be verified.
•I will report any changes in circumstances within TEN DAYS of when they happen.
•I know that it is against the law to obtain benefits to which I am not entitled. Any false claim, statement or concealment of any material fact whatsoever, in whole or in part, may subject me to criminal and/or civil prosecution.
•I agree that medical information about me can be released if needed to administer this program.
•I understand Healthcare benefits based on a person being blind, disabled, age 65 or over, pregnant women, child or parent, is not determined by completing this application. If I want eligibility for healthcare benefits explored on the basis of one of these, I must complete a different application for these benefits.
•Provided I am found to be eligible for Medicaid, I know the state of Missouri will pay for covered services on my behalf and agree the state may collect payments from any third party (i.e., insurance, estate, etc.) for services paid by the state.
•I understand the decision on my eligibility will be released to the State of Missouri BCCCP Program for tracking purposes.
•I understand that if I disagree with the decision concerning my eligibility, I may request a fair hearing within 90 days of the date of the decision.
•I understand I am entitled to fair and equal treatment regardless of my age, sex, race, color, handicap, religion, creed, national origin or political belief.
I agree that the 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
DATE
CALL
MO |
Mail this application to the MC+ Service Center in your Area (see map below).
MC+ Service Center
525 Jules St. #127
St. Joseph, MO 64501
Phone:
Fax:
MC+ Service Center
P.O. Box 318
Troy, MO
Phone:
Fax:
MC+ Service Center
P.O. Box 15188
Kansas City, MO 64106
Phone:
MC+ Service Center
3545 Lindell
St. Louis, MO
Phone:
Fax:
Fax:
MC+ Service Center
9900 Page Avenue
St. Louis, MO 63132
Phone:
Fax:
MC+ Service Center |
MC+ Service Center |
101 Park Central Square |
P.O. Box 578 |
Springfield, MO 65806 |
Cape Girardeau, MO |
Phone: |
Phone: |
Fax: |
Fax: |
MO