The MO 886 3977 form, also known as the Missouri Department of Social Services Division of Family Services BCCT (Breast and Cervical Cancer Treatment) Medical Assistance Application, is a crucial document for individuals seeking Medicaid assistance specifically for breast and cervical cancer treatments in Missouri. This detailed form requires applicants to provide personal information, including health insurance status, medical diagnoses, and household details, to determine eligibility for medical assistance under the BCCCP. For those in need of assistance with this process, a now-established approach involves carefully filling out and submitting this comprehensive application.
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The MO 886 3977 form, issued by the Missouri Department of Social Services Division of Family Services, serves as a critical document for individuals seeking medical assistance under the Breast and Cervical Cancer Treatment (BCCT) program. This comprehensive application requires personal information including name, social security number, and contact details, alongside detailed queries regarding the applicant's citizenship, healthcare insurance status, and living situation. It notably emphasizes the necessity for accuracy and honesty, underpinning the legal implications of providing false information. Applicants are reminded of the requirement to report any changes in their circumstances promptly and to understand the consequences of failing to do so. Furthermore, the form outlines the conditions under which medical information can be released for administrative purposes and details the process for contesting eligibility decisions, underscoring the applicant's rights to a fair hearing and non-discriminatory treatment. Critical to its function, the form guides applicants through the process of applying for Medicaid and other healthcare benefits, facilitated through various Missouri Care Plus (MC+) Service Centers across the state, with specific instructions on how and where to submit completed applications. This procedural document, while administrative in nature, plays a pivotal role in ensuring eligible individuals receive the healthcare support they require, outlining not just the steps to apply for assistance but also the legal and ethical obligations of applicants.
MISSOURI DEPARTMENT OF SOCIAL SERVICES DIVISION OF FAMILY SERVICES
BCCT MEDICAL ASSISTANCE APPLICATION
BCCCP PROVIDER
TELEPHONE NUMBER
DIAGNOSIS DATE
FOR OFFICE USE ONLY
DATE APPLIED
DCN
SERVICE REP
SUPERVISOR
LOAD
COMPLETE IN INK
A. MAILING ADDRESS
NAME (FIRST, MIDDLE, LAST)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
RACE/ETHNIC
ADDRESS (HOUSE NO., STREET, RURAL ROUTE, PO BOX NO) CITY, STATE, ZIP CODE COUNTY
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
MESSAGE PHONE NUMBER
B. INSTRUCTIONS: Please answer each question completely.
YES
NO
1. Are you a U.S. citizen? If “NO”, list immigration status and registration number, date of entry:
2. Do you currently have healthcare insurance?
NAME OF COMPANY AND POLICY NUMBER
TYPE OF COVERAGE
DOCTOR
HOSPITAL If limited coverage explain:
3.Do you have children under the age of 19 residing in your home?
4.Are you pregnant?
5.Are you blind?
6.Are you disabled?
C. PLEASE READ CAREFULLY AND SIGN BELOW:
•I agree to provide Social Security Numbers of all persons applying for Medicaid as required by law. The social security number is used to determine eligibility and verify information.
•I agree that my statements and information provided may be verified.
•I will report any changes in circumstances within TEN DAYS of when they happen.
•I know that it is against the law to obtain benefits to which I am not entitled. Any false claim, statement or concealment of any material fact whatsoever, in whole or in part, may subject me to criminal and/or civil prosecution.
•I agree that medical information about me can be released if needed to administer this program.
•I understand Healthcare benefits based on a person being blind, disabled, age 65 or over, pregnant women, child or parent, is not determined by completing this application. If I want eligibility for healthcare benefits explored on the basis of one of these, I must complete a different application for these benefits.
•Provided I am found to be eligible for Medicaid, I know the state of Missouri will pay for covered services on my behalf and agree the state may collect payments from any third party (i.e., insurance, estate, etc.) for services paid by the state.
•I understand the decision on my eligibility will be released to the State of Missouri BCCCP Program for tracking purposes.
•I understand that if I disagree with the decision concerning my eligibility, I may request a fair hearing within 90 days of the date of the decision.
•I understand I am entitled to fair and equal treatment regardless of my age, sex, race, color, handicap, religion, creed, national origin or political belief.
I agree that the signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete, to the best of my knowledge.
SIGNATURE
DATE
CALL 1-888-275-5908 IF YOU HAVE ANY QUESTIONS.
MO 886-3977 (9-01)
IM-1BC (9-01)
Mail this application to the MC+ Service Center in your Area (see map below).
MC+ Service Center
525 Jules St. #127
St. Joseph, MO 64501
Phone: 816-387-2070
Fax: 816-387-2289
P.O. Box 318
Troy, MO 63379-0138
Phone: 636-528-8521
Fax: 636-528-2748
P.O. Box 15188
Kansas City, MO 64106
Phone: 816-889-2438
3545 Lindell
St. Louis, MO 63103-1077
Phone: 314-340-5505
Fax: 314-340-5096
Fax: 816-889-2346
9900 Page Avenue
St. Louis, MO 63132
Phone: 314-426-8508
Fax: 314-429-7961
101 Park Central Square
P.O. Box 578
Springfield, MO 65806
Cape Girardeau, MO 63702-0578
Phone: 417-895-6757
Phone: 573-290-5800
Fax: 417-895-6763
Fax: 573-290-5219
Completing the MO 886-3977 form is a significant step in applying for Medical Assistance through the Missouri Department of Social Services, Division of Family Services. The form requires accurate and complete information regarding your current situation, insurance coverage, and health status. Take your time to gather all necessary information before starting. Careful and honest completion of the form will support a smooth assessment process for determining your eligibility for benefits.
Steps for Filling Out the MO 886-3977 Form:
Once your application is submitted, the Missouri Department of Social Services will review the information you provided to determine your eligibility for Medical Assistance. The review process includes verifying the accuracy of your responses and may require additional documentation. You will be notified of the decision, and if eligible, detailed information regarding the benefits and how to use them will be provided. Remember, assistance is available if you have questions or need guidance during the application process by calling the number provided on the form.
The MO 886 3977 form is designed for individuals applying for medical assistance in Missouri. It is specifically associated with the Breast and Cervical Cancer Treatment (BCCT) Program under the Division of Family Services, Missouri Department of Social Services. This form allows applicants to provide their personal information, declare their citizenship status, healthcare insurance status, and disclose any disabilities or conditions that might affect their eligibility for assistance.
This form should be completed by individuals seeking medical assistance through Missouri's Breast and Cervical Cancer Treatment Program. It is important for applicants who are currently uninsured or underinsured, are U.S. citizens or lawfully present immigrants, and who have been diagnosed with breast or cervical cancer, or are in need of treatment for these conditions. Applicants are required to fully answer all questions and provide accurate information to the best of their knowledge.
The MO 886 3977 form can be submitted to the MC+ Service Center corresponding to the applicant's area. Submission can be done via mail or fax. Specific addresses and fax numbers for each MC+ Service Center are provided on the form, including centers in St. Joseph, Troy, Kansas City, St. Louis, and Springfield, among others. Applicants should choose the service center closest to their location for faster processing of their application.
Applicants are encouraged to read the form carefully, ensure all sections are completed accurately, and sign the declaration to certify the truthfulness of the information provided.
When applying for medical assistance through the Missouri Department of Social Services' BCCT Medical Assistance Application (form MO 886-3977), accuracy and thoroughness are crucial. However, individuals often make mistakes that can delay processing or impact their eligibility. Understanding these common errors can help applicants avoid them.
Not completing the form in ink. The instructions specify that the application should be filled out in ink, which reduces the chance of alterations and ensures the information is legible.
Failing to answer each question completely. Each question is designed to gather specific information critical to determining eligibility. Incomplete answers can lead to requests for additional information, causing delays.
Omitting the Social Security number. The application requires applicants to provide Social Security numbers for all persons applying for Medicaid, a necessary step for eligibility verification.
Incorrect or missing immigration status information for non-U.S. citizens. Applicants who are not U.S. citizens must list their immigration status and registration number, crucial for eligibility determination.
Not reporting changes in circumstances within ten days. The application obliges applicants to report any changes in circumstances, such as income or household size, which could affect eligibility.
Forgetting to sign and date the application. The signature certifies that all information provided is true and accurate under penalty of perjury. An unsigned application cannot be processed.
Ensuring the correctness and completeness of the information on the MO 886-3977 form is a shared responsibility. Applicants can seek assistance or clarification on any part of the application by calling the number provided on the form. Vigilance in avoiding these common mistakes can expedite the application process and assistance delivery. Those unsure about any part of the application process should not hesitate to reach out for support. This helps ensure that individuals and families in need can receive assistance promptly and efficiently.
When individuals apply for medical assistance through the Missouri Department of Social Services using the MO 886-3977 form, they often need to provide additional forms and documents to support their application. These documents play a crucial role in ensuring that the application process is comprehensive and that the assessing authorities have all necessary information to make an informed decision regarding eligibility and the level of assistance required. Below is a list of forms and documents commonly used alongside the MO 886-3977 form:
Collecting and submitting these documents alongside the MO 886-3977 form provides a complete picture of the applicant's situation, allowing for accurate assessment and timely processing of medical assistance applications. It's important for applicants to ensure that all information provided is accurate and up-to-date to avoid delays or denial of benefits.
The MO 886-3977 form, employed by the Missouri Department of Social Services, Division of Family Services, for the application of Breast and Cervical Cancer Treatment (BCCT) Medical Assistance, bears resemblance to several other documents commonly utilized in public health and social services. Primarily, this application form is aimed at collecting essential information from applicants seeking medical assistance under the BCCCP (Breast and Cervical Cancer Control Project), including personal identity, healthcare coverage, and need-based qualifying conditions. The structure and content of the MO 886-3977 form reflect a comprehensive approach to determining eligibility and facilitating access to necessary healthcare services.
One closely related document is the Standard Medicaid Application form used across various states for regular Medicaid enrollment. This form, much like MO 886-3977, requests detailed personal and financial information to assess eligibility for Medicaid services. Both documents require applicants to disclose their citizenship status, current healthcare insurance coverage, household composition, and special condition considerations, such as pregnancy or disability status. The key similarity lies in their shared objective to streamline access to Medicaid by providing a clear, structured pathway for applicants to demonstrate their eligibility. However, the MO 886-3977 form is specifically tailored to individuals applying for coverage under the BCCCP, focusing on cancer treatment assistance, while the Standard Medicaid Application serves a broader audience seeking general healthcare coverage through Medicaid.
Another document that mirrors the MO 886-3977 form is the Children’s Health Insurance Program (CHIP) Application. Both of these documents are designed with the intention of facilitating healthcare benefits for specific groups — in the case of CHIP, for children under the age of 19 who do not qualify for Medicaid. Similar to the MO 886-3977, the CHIP Application includes sections for demographic information, healthcare insurance status, and living arrangement details. They both feature questions about household income and size to ascertain the applicants' financial standing and eligibility. The standout similarity is the incorporation of eligibility criteria based on specific health needs and socioeconomic factors, underscoring the targeted approach of each program to extend healthcare services to vulnerable populations.
Therefore, while the MO 886-3977 form is uniquely structured to address the needs of individuals applying for BCCT Medical Assistance in Missouri, its fundamental elements of personal identification, insurance details, and health condition inquiries align with the broader framework of applications for Medicaid and CHIP. Each document serves as a critical tool in the process of evaluating eligibility and providing necessary healthcare access, reflecting the overarching aim of public health and social services systems to support well-being and medical care access for all citizens, especially those in dire need.
When completing the Missouri Department of Social Services' Division of Family Services BCCT Medical Assistance Application (form MO 886-3977), there are several key steps and precautions to keep in mind. Ensuring accuracy and thoroughness in your application can make a significant difference in the processing time and outcome of your application. Here are some dos and don'ts:
Do:
Don't:
When dealing with the MO 886 3977 form, it's crucial to navigate through some common misconceptions to understand its purpose and requirements accurately. This document serves as an application for medical assistance under the Missouri Department of Social Services, Division of Family Services. Here are some misconceptions and clarifications.
Understanding these misconceptions helps in approaching the application process with more clarity and ensures that individuals provide the necessary information accurately, which is crucial for accessing healthcare benefits efficiently.
Understanding the Missouri Department of Social Services' MO 886-3977 form is key to successfully applying for medical assistance through BCCT. Here are seven vital points to remember:
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