Application Form

A participant may apply by submitting a completed application form to FSD.

The Application for Health Coverage & Help Paying Costs (IM-1SSL) can be:

Accessed online in the DSSManuals Forms Manual

Picked up at FSD offices. Participants can find the nearest location on FSD’s website, https://dss.mo.gov/offices.htm

Note: Participants can apply for both MHN and Medicare Savings Programs (MSP) using the IM-1SSL. Participants requesting ONLY MSP must use Application for Medicare Savings Programs (IM-1MSP) .

Mailed to participants upon request for an application form. Participants may request an application form by phone or by written request.

Note: Anyone can request an application. Application requests from a third party (such as a family member, or community partner) can be sent to the participant or the third party. Do NOT provide any case-specific information about active cases or pending applications to an unauthorized third party.

An application form may be submitted:

Online by using the FSD Upload Portal at mydssupload.mo.gov

By mailing the form to Family Support Division, PO BOX 2700, Jefferson City, MO 65102

By faxing the form to 573-526-9400

In person by returning the completed form to an FSD office

When an application form is received, staff must verify the application contains a valid signature and must date stamp with the application date. For information regarding valid signatures, see 1802.020.00 Signing the Application and its subsections.

The application date for an application form is the date that the signed application form is received by FSD. If the application form is submitted on a weekend, holiday, or after business hours, the application is received as of the next business day.