Get Mo 650-0216n 1999-2026

The MO 650-0216N is a standard means test financial questionnaire used by the Missouri Department of Mental Health. This guide provides step-by-step instructions to assist users in confidently completing the form online.

Follow the steps to complete the MO 650-0216N online.

1. Press the ‘Get Form’ button to access the MO 650-0216N and open it in your preferred online editor.
2. Begin by entering your facility information at the top of the form, including the date and the client's information such as last name, date of birth, first name, middle initial, case number, and Medicaid number.
3. If the client is school-aged, provide the name of the domicile school district. Also, include the branch of service and service number if applicable.
4. Indicate the name of the person to be billed, the date the client was admitted, the number in the household, and the Medicare number if the client is a veteran, including the dates of service.
5. If the client has changed their address in the last six months, fill in the previous address details. This includes the street address, city, state, and ZIP code.
6. Answer the health insurance question. If applicable, provide the name and address of the insurance company and the policy/group number.
7. Indicate employment status for the client and/or financially responsible person and provide employer details as needed.
8. Fill out the income section (Section C), which includes multiple lines for listing various income sources. Mark 'Yes' or 'No' for each source and provide corresponding amounts and pay periods.
9. Complete the income conversion section for departmental use, including extraordinary medical expenses if applicable. Calculate total monthly income.
10. Answer additional questions about other household members receiving services through DMH and whether someone else receives the client's government check.
11. If applicable, provide details regarding parents or spouse, personal property, real property, life insurance, and prepaid burial plans.
12. In the remarks section, include any additional relevant information.
13. Sign the certification section, confirming the accuracy of the information provided, and include the date. Optionally, the interviewer can also sign.
14. After completing the form, make sure to save changes, download, print, or share the completed MO 650-0216N as needed.

Start filling out the MO 650-0216N online to ensure a smooth application process.