This is an alternative to applying for Medicaid, provide the information you can in the form and it will be saved to an account where you can come back and check the status of your application later.

    While logged in, you can view the status of your application's approval state.

    This website is not the only place you can apply, for other options check out our provided resources

Who Completes This Section?

  • Applicant - Fill out your personal information
  • Authorized Representative - If completing on behalf of applicant, you may fill this out
  • All fields marked with * are required
Applicant Information
Enter your legal first name as it appears on official documents
Choose the primary form of identification you have available
Only the last 4 digits are requested for privacy protection.
Optional - We'll use this to send updates about your application
Missouri residents only - this form is for Missouri Medicaid
Fields marked with * are required. Need help? Call (855) 373-4636

Who Completes This Section?

  • Applicant - Provide details about your current employment status
  • Multiple Jobs? Focus on your primary job, note others in the comments
  • Self-Employed? Provide your business information and average income
Employment Details
When did you start this job?
Typical number of hours you work each week
Enter hourly rate OR annual salary amount
Include commission, tips, or irregular bonuses
This information helps our team better understand your employment situation

Who Completes This Section?

  • Applicant - Provide your employer's contact information
  • HR Contact - Person who can verify your employment
  • Self-Employed? Use your business information and accountant/CPA if applicable
Employer Contact Information
Official business name (for self-employed, use your business name)
Federal tax ID number - found on tax documents or W-2
Main business address or HR department location
Person who can verify your employment (manager, HR, payroll)

Who Completes This Section?

  • Applicant - Upload or describe employment verification documents
  • Photo uploads accepted - You can take photos of documents with your phone
  • Mail/Fax option - Describe what you'll send if not uploading
Upload or Describe Employment Documents

Accepted File Types & Photo Options:

Documents: PDF, DOC, DOCX Images/Photos: JPG, JPEG, PNG, HEIC Mobile Photos: You can take photos of pay stubs, letters, etc. with your phone File Limit: Up to 10 files, 5MB each
Select multiple files or take photos of documents. Demo only - files not actually processed.
Describe documents you'll send by mail, fax, or bring in person
Helpful Document Examples:
  • Recent pay stubs (last 2-4 pay periods)
  • Letter from employer on company letterhead
  • Bank statements showing direct deposits
  • Tax forms (W-2, 1099, etc.)
  • Self-employment: Business license, contracts, invoices

Who Completes This Section?

  • Applicant - Must provide your own consent and signature
  • Authorized Representative - May sign if legally authorized
  • Guardian/Conservator - May sign for incapacitated individuals
Authorization & Signature

By signing, you agree that the Missouri Department of Social Services (DSS) may contact your employer and use the information provided to determine or renew your Medicaid eligibility.

Your consent allows us to verify employment details with your employer
Type your full legal name exactly as it appears on your ID
Example: Parent, Guardian, Power of Attorney, etc.
Privacy Notice & Translation Services:

Your information is protected under state and federal privacy laws. Do not email documents containing Social Security Numbers unless instructed to use a secure method.

Language Services: Free interpretation and translation services are provided by Missouri Medicaid in Spanish, Somali, Vietnamese, Arabic, Bosnian, and other languages. Call (855) 373-4636 to request language assistance.

Additional Resources