Aged, Blind, and Disabled Supplement (IM-1ABDS)

Format date: MM/DD/YYYY

or

Complete this supplement if you are requesting health coverage for anyone through the aged, disabled, blind, or long-term care programs. This is to be completed in addition to the Application for Health Coverage & Help Paying Costs (IM-1SSL) application.

This supplement does NOT meet the requirements of an application without the IM-1SSL.

To explore MO HealthNet for the Aged, Blind, and Disabled health care for you and/or your spouse.

If yes, please provide proof or complete this form, Appointing an Authorized Representative.  

For Home and Community Based Services, Vendor (nursing home), and Supplemental Nursing Care applicants:

For Blind Pension and Supplemental Aid to the Blind applicants:


Money & Accounts:

Fill out the info below to tell us about the things you (and your spouse, if married) own, such as bank accounts, stocks, bonds, life insurance, real estate, and personal property.

Money may include cash that is in your possession, at home, or that someone else is holding for you. Accounts may include:

  • Checking

  • Retirement Accounts

  • Life insurance (with cash value)

  • Savings

  • Annuities

  • Cryptocurrency

  • Prepaid or direct deposit cards

  • Stocks, bonds, investments

  • Trusts

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

If yes, we must review the entire trust. You must provide a complete copy including any amendments.

Vehicles

If Yes, provide information below for all cars, trucks, recreational vehicles, watercraft, or other vehicles.

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Real Estate Property:

If Yes, provide information below for any houses, buildings, rental property, land/lots, or other property.

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Personal Property

If Yes, provide information below.

This may include:

  • Mobile (trailer) Home
  • Livestock, grain, produce, farm, equipment, tools, etc.
  • Business equipment
  • Household furniture (in storage)

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Transfer of property or assets: Tell us what property has been sold or given to others.

If yes, fill out the information below:

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Life insurance and pre-paid burial plans

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Health Insurance

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Long-term Care Insurance

To add more than 1 asset, click the (+) button. To remove added assets (or blank fields added in error), click the (-) button

Complete & Submit

Once you click Submit, the information provided will be sent to Family Support Division and reviewed for any active cases or pending applications. If you do not have a pending application, submit an application through the online portal, or call 855-373-9994 to apply by phone.

You may submit any supporting documents by:

  • Email: FSD.Documents@dss.mo.gov
  • MailFamily Support Division
    •     615 E 13th St
    •     Kansas City, MO 64106
  • Fax: 573-526-9400      

If you have questions about your pending application, or the information you submitted, call the Family Support Division Customer Service Center at 855-373-4636. 

 

Thank You

Dear {formsubmittinguser},

Thank you for completing your Aged, Blind, and Disabled Supplement for your MO HealthNet application. 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.

If you have any questions about your Aged, Blind, and Disabled Supplement or your pending MO HealthNet application, 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 Aged, Blind, and Disabled Supplement 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