Applications and Forms

Home and Community Based Services

HCBS Referral Form (DA-1)

Money Follows the Person

Request for Supplemental Transition Funds

Provider Billing Forms

Explanation of the Non-Medicaid Eligibility Consumer Payment Summary
Non-Medicaid Eligibility (NME) Consumer Payment Summary
NME Invoice
Adult Day Care Waiver Participant Invoice
Explanation of the Adult Day Care Waiver (ADCW) Participant Payment Summary
SSBG/GR Advanced Respite Invoice
SSBG/GR In-Home Services Invoice
SSBG/GR Nurse Respite Invoice

Direct Deposit Information

Vendor ACH/EFT Application - (This form is for SSBG/GR payments only)

The Application for Provider Direct Deposit form must be used for MO HealthNet payments.  The form is available at the MO HealthNet Division’s web site.  A form must be submitted for each MO HealthNet provider number.