mdhhs-5640, beneficiary status notification

Michigan Department of Health and Human Services (MDHHS)

Maternal Infant Health Program (MIHP)

(Revised 10-25)

Your patient, identified below, participates in the Maternal Infant Health Program (MIHP), a home visiting program intended to promote healthy pregnancies, positive birth outcomes, and healthy infant development. MIHP services are provided by a Registered Nurse and a Licensed Social Worker. Additional services may be provided by a Registered Dietitian, Infant Mental Health Specialist and IBCLC Lactation Consultant. To learn more about MIHP, Michigan's largest home visiting program for Medicaid-eligible pregnant women and infants, visit www.michigan.gov/mihp.

SECTION 1

Medical Care Provider	Phone Number	Fax Number

Medical Care Provider Email

Medical Care Provider Address	City	State	Zip Code

Health Plan	FFS*	Date

Beneficiary	Medicaid ID	Date of Birth

Beneficiary enrolled in MIHP (Prenatal or Infant Care Communication attached).

Beneficiary transferred to our MIHP from another MIHP.

Notification to new medical care provider (Prenatal or Infant Care Communication attached).

Beneficiary discharged from MIHP (Discharge Summary attached).

Comments

If you have questions or comments about MIHP services provided to this beneficiary, please contact:

MIHP Staff Name	Telephone Number	Fax Number

MIHP Agency Name

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

BENEFICIARY STATUS NOTIFICATION INSTRUCTIONS

These instructions are intended to clarify data fields. If you have additional questions, please contact the MDHHS MIHP Team.

The Beneficiary Status Notification form letter is used to communicate with the beneficiary’s medical care provider in four situations. Check the appropriate box and attach the specified document or note additional information on the letter itself.

Medical Care Provider or Clinic (Phone, Fax, Email, Address): Insert the beneficiary’s medical care provider or clinic’s name and the contact information that will be used to send this form to that office. If a specific type of contact information is not known, you may leave the area blank or add N/A.

Health Plan, Date: Insert the name of the beneficiary’s Health Plan or check FFS (Fee-For-Service) and insert the date the form is completed.

Beneficiary, Medicaid ID, Date of Birth: Insert beneficiary’s name, their Medicaid ID and date of birth.

Beneficiary enrolled in MIHP (Prenatal or Infant Care Communication) attached.

Attach the completed Prenatal or Infant Care Communication form.

The medical care provider must be notified of MIHP enrollment within 14 calendar days after the Risk Identifier visit is completed or 14 calendar days after the identification of a medical provider.

Beneficiary transferred to our MIHP from another MIHP.

Check the box. You need not provide any additional information.

Notification to new medical care provider. (Prenatal or Infant Care Communication attached.)

Attach a copy of the Prenatal or Infant Care Communication form that was sent to the beneficiary’s previous medical care provider.

Beneficiary discharged from MIHP (Discharge Summary attached):

Attach the completed Discharge Summary.

The medical care provider must be notified of discharge within 14 calendar days from the date that the Discharge Summary data is entered into the MIHP database.

Comments: Use this space to add any other information that you think would be useful for the medical care provider.

MIHP Staff Name, Telephone Number, Fax Number, MIHP Agency Name: The staff member completing the form should insert their name, MIHP agency name and contact information. Support staff may complete and forward this form to the medical care provider.