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MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION FACILITY NOTIFICATION INFORMATION SHEET IM-72FNIS (7/2026) FROM (FACILITY NAME): FACILITY ADDRESS: FACILITY CONTACT PERSON: MAILING ADDRESS (IF DIFFERENT): FACILITY PHONE: FACILITY EMAIL FACILITY FAX: Application Change in Circumstances Verification Resident’s Name: Date of Birth: Spouse’s Name: Date of Marriage Social Security Number: DCN (if known): NOTIFICATION AND DATE OF: (Please write date of event in appropriate space below.) New Admission

Discharge

Death NEW ADMISSION: (Please complete 1-5 for all admissions, and 6 or 7 if applicable.) 1. Admitted from? Home: Hospital: Other Facility: 2. Date DA-124 sent to COMRU: 3. Date entered a Medicaid-certified bed: 4. Placement (check one): SNF ICF RCF I ALF/RCF II DMH 5. Bed type (check one): ALF ICF MHC PSY RC1 SNF Title 18 Title 19 6. If RCF or ALF monthly base rate for resident: 7. Guardian or Responsible Party and relationship: Address: Phone: DISCHARGE: (Please complete 1 or 2.) 1. New facility – facility name and city: 2. Other living arrangement – individual’s current address and telephone number: CHANGE: (Please complete as needed.) 1. Describe the change: 2. If requesting a review or adjustment to surplus, please explain below: