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Medicaid Provider Forms and Other Resources

Agency: Community Health, Department of

This page contains copies of forms commonly used by Medicaid providers. Most forms are provided in both PDF and Word 2000 fill-in enabled formats. If you have any problems with documents found on this page, please e-mail us at MSA-FORMS@michigan.gov

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FORMS: 

Form Number

Name & Description

WORD

PDF

DCH-0078 Request to Add, Terminate or Change Other Insurance XXXX  XXX 
DCH-0893  Vision Services Approval/Order  XXXX  XXX 
MSA-0891  Provision of Low Vision Services XXXX  XXX 
MSA-0892  Documentation of Medical Necessity for Provision of Contact Lenses XXXX  XXX 
DCH-1074  Hospice Membership Notice  XXXX  XXX 
DCH-1185  Nursing Facility Request to Disenroll from Medicaid Health Plan  XXXX  XXX 
DCH-1190  Maternal Infant Health Program Authorization and Consent to Release Protected Health Information  XXXX  XXX 
DCH-1401   Electronic Signature Agreement   XXXX   
DCH-1421 Provider Application for Registry XXXX   
DCH-1575  Nurse Practitioner/Physician Agreement  XXXX  XXX 
DCH-3877  Preadmission Screening (PAS)/Annual Resident Review (ARR) (Mental Illness Developmental Disability Identification) XXXX  XXX 
DCH-3878  Mental Illness/Developmental Disability Exemption Criteria Certification (For Use in Claiming Exemption Only) XXXX  XXX 
DCH-3890  Electronic Signature Verification Statement  XXXX  XXX 
MSA-0207  Stockroom Requisition (MSA forms and publications only)  XXXX   

MSA-0209

Request to Participate in Policy Proposal Review

XXXX 

XXX 
MSA-0725  Application for Payment of Health Insurance Premiums(CSHCS)  XXXX  XXX 
MSA-0732  Prior Authorization for Private Duty Nursing (PDN) for Children's Special Health Care Services (CSCHS)  XXXX  XXX 
MSA-0838  Authorization to Disclose Protected Health Information (CSHCS)  XXXX  XXX 
MSA-1134  Authorization to Disclose Protected Health Information for MOMS  XXXX  XXX 
MSA-1142  Maternity Outpatient Medical Services (MOMS) Enrollment Notice  XXXX  XXX 
MSA-1200  Maternal Infant Health Program - Prenatal Risk Factor Eligibility Screening Form  XXXX  XXX 
MSA-1302  Beneficiary Monitoring Program Referral  XXXXX  XXX 
MSA-1324  Nurse Aid Training and Testing Certification Reimbursement  XXX  - Excel   
MSA-1326  Certified Nurse Assistant Training Reimbursement    XXX 
MSA-1532  Blood Lead Results  XXXX   
MSA-1550 Recipient Verification of Coverage XXXX  XXX 
MSA-1380 835 - Electronic Remittance Advice Request for Billing Agent Change/Update XXXX  XXX 
MSA-1653B  Special Services Prior Authorization - Request/Authorization Form  XXXX  XXX   - with instructions
MSA-1653-C  ACD Evaluation Form - See MSA 06-18 Policy Bulletin -must use MSA-115

MSA-115 

 
MSA-1653-D Complex Seating and Mobility Device Prior Approval - Request/Authorization XXXX  XXX 
MSA-1656  Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices XXXX  XXX 
MSA-1656 Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices Addendum A: Mobility/Seating XXXX  XXX 
MSA-1656 Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices Addendum B: Strollers, Gait Trainers, Standers, Car Seats, and Children's Positioning Chairs XXXX  XXX 
MSA-1680-B  Dental Prior Authorization Request  XXXX  XXX - with instructions 

MSA-1959

Consent to Sterilization

 

XXX 

MSA-1576  Complex Care Prior Authorization-Request/Authorization for Nursing Facilities  XXXX  XXX 
MSA-1580  Request for Authorization of Private Room Supplemental Payment for Nursing Facility  XXXX  XXX 
MSA-1755 Medicaid Enrolled Birthing Hospital Agreement for Elective, Non-Medically Indicated, Delivery Prior to 39 Weeks Completed Gestation XXXX  XXX 

MSA-2218

Acknowledge of Receipt of Hysterectomy Information

 

XXX 

MSA-2400  Freedom of Choice - Home and Community Based Services Waiver for the Elderly and Disabled  XXXX  XXX  
MSA-2565-C  Facility Admission Notice  XXXX  XXX 
MSA-3008  Certification of Medical Necessity for Enteral Formulas, Supplies and Equipment  XXXX  XXX 
MSA-4114  Medical Eligibility Report (MERF) - CSHCS  XXXX  XXX 

MSA-4240

Certification for Induced Abortion

XXXX 

XXX 

MSA-115

OT/PT-Speech Pathology Prior Approval - Request/Authorization

XXXX - Form Only

XXX - with instructions

MSA-4674 

Medical Transportation Statement 

XXXX  XXX 

MSA-4674A

Medical Transportation Statement - Chronic Ongoing Treatment

XXXX  XXX 

OTHER RESOURCES:

Name & Description

WORD

PDF

Nursing Facility Eligibility (MDCH-726)    XXX 
Know Your Rights - Your Medicaid Care and Coverage in a Nursing Facility (MDCH-731 Publication)   

XXX 



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