Fill in a Valid Mo 886 3977 Form Open Document Now

Fill in a Valid Mo 886 3977 Form

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.

If you're looking for assistance with your application or need more information on how to fill out the MO 886 3977 form accurately, click the button below to get started.

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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.

Example - Mo 886 3977 Form

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:

YES

NO

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

MC+ Service Center

P.O. Box 318

Troy, MO 63379-0138

Phone: 636-528-8521

Fax: 636-528-2748

MC+ Service Center

P.O. Box 15188

Kansas City, MO 64106

Phone: 816-889-2438

MC+ Service Center

3545 Lindell

St. Louis, MO 63103-1077

Phone: 314-340-5505

Fax: 314-340-5096

Fax: 816-889-2346

MC+ Service Center

9900 Page Avenue

St. Louis, MO 63132

Phone: 314-426-8508

Fax: 314-429-7961

MC+ Service Center

MC+ Service Center

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

MO 886-3977 (9-01)

File Attributes

Fact Name Description
Form Number MO 886-3976
Form Title BCCT Medical Assistance Application
Issuing Department Missouri Department of Social Services, Division of Family Services
Purpose The purpose of this form is to apply for Medicaid assistance for breast and cervical cancer treatment.
Key Sections Applicant Information, Insurance Information, Agreement and Signature
Governing Law(s) Administered under the laws of the State of Missouri related to healthcare and public assistance.
Application Process Applicants are required to provide complete and accurate information regarding citizenship, healthcare insurance, household composition, and any disabilities or special conditions.
Verification Requirement Applicants must agree that their provided information may be verified and that Social Security Numbers are required by law for all individuals applying for Medicaid.
Reporting Requirement Changes in circumstances must be reported within ten days of occurrence to remain eligible for benefits.
Eligibility for Other Benefits Applying for healthcare benefits based on blindness, disability, age, or pregnancy requires a different application form.
Signature and Perjury Statement Applicants certify under penalty of perjury that all provided information is true and complete.

How to Write Mo 886 3977

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:

  1. Begin by filling out the "FOR OFFICE USE ONLY" section with the current date, and leave the rest for office personnel.
  2. In section A, write your full name, date of birth, and social security number. Also, include your race/ethnicity and your complete mailing address, including county and phone numbers (home, work, and a message phone number if available).
  3. Move to section B: Instructions. Here, you need to answer all the questions honestly. For each question, check the appropriate box—'YES' or 'NO.' If additional information is requested, such as your immigration status, healthcare insurance details, or clarification on limited healthcare coverage, provide clear and precise answers.
  4. In case you have healthcare insurance, specify the name of the company, and the policy number along with the type of coverage (Doctor, Hospital).
  5. For questions about children under the age of 19 in your household, pregnancy status, blindness, or disability, answer accurately to reflect your current situation.
  6. Read section C carefully. This section contains crucial declarations about the provision of social security numbers, agreement to verification of your statements, obligation to report changes in circumstances, understanding of legal consequences for false claims, consent for medical information release, acknowledgment of benefits limitation, third-party payment agreement, eligibility decision notification, right to a fair hearing, and entitlement to fair and equal treatment.
  7. After carefully reading section C, sign and date the form at the bottom, certifying that your declarations are true and complete to the best of your knowledge, under penalty of perjury.
  8. Finally, choose the nearest MC+ Service Center based on the list provided at the end of the form. Mail your completed application to the selected center's address. Be sure to keep a copy for your records.

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.

What You Should Know About This Form

What is the MO 886 3977 form used for?

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.

Who should complete the MO 886 3977 form?

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.

How can I submit the MO 886 3977 form?

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.

What are the key sections of the MO 886 3977 form?

  • Section A: Requires personal information such as name, date of birth, social security number, and contact details.
  • Section B: Contains a series of yes/no questions regarding the applicant's citizenship status, current healthcare insurance, living situation, and medical conditions.
  • C: Includes a declaration that must be read carefully and signed by the applicant, acknowledging the accuracy of the information provided and agreeing to the terms and conditions listed.

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.

Common mistakes

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.

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

Documents used along the form

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:

  • Proof of Income: This includes current pay stubs, tax returns, or statements from employers. It's essential for determining the financial eligibility of the applicant.
  • Proof of Residence: Items like utility bills, a lease agreement, or mortgage statements help establish the applicant's residence in Missouri.
  • Proof of Citizenship or immigration status: This can be a birth certificate, passport, or immigration documents, which are necessary to establish eligibility for state-funded assistance.
  • Proof of Disability (if applicable): Documents such as letters from Social Security Administration, medical records, or documentation from physicians confirming a disability are crucial for applicants claiming disability benefits.
  • Social Security Numbers for all applying members: A requirement for processing the application, as stated in the MO 886-3977 form.
  • Health Insurance Information: If the applicant currently has health insurance, details including company name and policy number are required. This helps determine potential coordination of benefits.
  • Additional Application for Other Benefits: Such as food stamps or Temporary Assistance for Needy Families (TANF), if the applicant wishes to apply for multiple forms of state assistance simultaneously.

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.

Similar forms

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.

Dos and Don'ts

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:

  1. Fill out the form in ink to prevent smudging and ensure legibility.
  2. Provide complete answers to each question to avoid delays in processing.
  3. Include the Social Security Numbers for all persons applying, as this is a legal requirement for Medicaid eligibility determination.
  4. Report any changes in your circumstances within ten days, to ensure your information is up to date.
  5. Understand that by signing the application, you agree to the verification of your statements and information provided.
  6. Indicate if you or any family member has specific healthcare needs or statuses, such as being pregnant or disabled, which may affect your eligibility.
  7. Be aware that Medicaid may pursue third-party payments if you are found to be eligible and receive coverage.
  8. Keep a copy of your completed application for your records.
  9. Sign and date the application to certify that your information is accurate to the best of your knowledge and understanding.
  10. Contact the provided numbers if you have any questions or need clarification on the application process.

Don't:

  1. Leave any sections blank; incomplete applications can lead to processing delays or denials.
  2. Guess on dates or numbers; verify all information for accuracy before submission.
  3. Conceal any material facts or attempt to provide false information; this can lead to criminal and/or civil prosecution.
  4. Forget to read the certification and rights section carefully before signing.
  5. Assume you're not eligible for Medicaid without applying; eligibility criteria can be extensive and varied.
  6. Fail to report changes in your situation, as this can affect your eligibility and lead to recoupment of benefits.
  7. Ignore the guidelines for submitting additional documentation that supports your application.
  8. Hesitate to request a fair hearing if you disagree with the eligibility decision within 90 days.
  9. Overlook the state's right to collect payments from third parties for services rendered under Medicaid.
  10. Send the application to the wrong service center; ensure it is mailed to the correct address for your area.

Misconceptions

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.

  • Only U.S. citizens can apply: It's a misconception that only U.S. citizens are eligible to apply for assistance through this form. Applicants who are not U.S. citizens but have a legal immigration status can also apply, provided they list their immigration status and registration number.
  • It's for immediate healthcare coverage: Some believe completing this form will immediately provide healthcare coverage. However, it's an application process that requires evaluation, and eligibility must be determined first.
  • You can’t apply if you have existing healthcare insurance: This is incorrect. Even if you currently have healthcare insurance, you can apply for Medicaid. The form even includes a section to detail your existing insurance coverage.
  • It covers all types of healthcare benefits: Another common misconception is that this form applies to all healthcare benefits. In reality, if you're seeking benefits based on being blind, disabled, aged 65 or over, pregnant, a child, or a parent, a different application may be necessary.
  • Only adults can apply: This form isn’t exclusively for adults. It asks if you have children under 19 residing in your home, indicating provisions for child healthcare benefits as well.
  • The process is entirely paper-based: While this form can be mailed, the inclusion of phone numbers and a notice to call if there are any questions suggests that additional support and potentially other methods of communication are available.
  • Submitting false information carries no penalties: The form clearly states that any false claim, statement, or concealment of any material fact may subject the applicant to criminal and/or civil prosecution, highlighting the seriousness of providing accurate information.
  • All applicants receive equal benefits: Benefits are tailored based on individual circumstances, needs, and eligibility criteria. Saying that all applicants receive equal benefits oversimplifies the nuanced process of determining what specific assistance an individual qualifies for.

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.

Key takeaways

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:

  • The MO 886-3977 form is designed for individuals applying for medical assistance under the BCCT (Breast and Cervical Cancer Treatment) Program. It is necessary to fill it out accurately to ensure eligibility and access to healthcare benefits.
  • Applicants must complete the form in ink, providing details such as mailing address, date of birth, social security number, and contact information. This ensures that the application can be processed efficiently.
  • When answering the questions in section B, it's crucial to answer completely and truthily. Questions range from citizenship status to current healthcare coverage and family composition.
  • All individuals applying for Medicaid must provide their Social Security Numbers as required by law. This is used for eligibility determination and information verification purposes.
  • Applicants agree to report any changes in circumstances within ten days. This includes any changes in income, family size, or insurance coverage, ensuring that eligibility and benefits are always accurate.
  • The form also serves as an agreement that the state of Missouri has the right to collect payments from any third party (like insurance or an estate) for services paid by Medicaid on the applicant's behalf.
  • In case of disagreement with the eligibility decision, applicants have the right to request a fair hearing within 90 days from the decision date. This ensures that applicants have a chance to contest decisions they believe are incorrect.
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