Medicaid Provider Forms and Other Resources

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


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 and Aids Support Documentation XXXX  XXX 
MSA-0892  Documentation of Medical Necessity for the Provision of Contact Lenses XXXX  XXX 
DCH-1190  Maternal Infant Health Program Authorization and Consent to Release Protected Health Information  XXXX  XXX 
MSA-181

Home Health Aide Prior Approval Request/Authorization

XXXX XXX
DCH-1401   Electronic Signature Agreement   XXXX   XXX
MDHHS-5405 Electronic Signature Agreement Cover Sheet XXXX  XXX
DCH-1421 Provider Application for Registry XXXX   XXX
DCH-1575  Nurse Practitioner/Physician Agreement  XXXX  XXX 
DCH-3877  Preadmission Screening (PAS)/Annual Resident Review (ARR) (Mental Illness/Intellectual Disability/Related Conditions Identification) XXXX  XXX 
DCH-3878  Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification (For Use in Claiming Exemption only) XXXX  XXX 

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  Private Duty Nursing Prior Authorization - Request for Services 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 - Maternal Risk Identifier XXXX  XXX 
MSA-1302  Benefits Monitoring Program Referral  XXXXX  XXX 
MSA-1324  Nurse Aide Training and Testing Program Interim Reimbursement Request  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-1653B  Special Services Prior Approval - Request/Authorization   XXXX  XXX   - with instructions
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-1904 Home Help Agency Invoice XXXX -with instructions  
MSA-1680-B  Dental Prior Approval Authorization Request  XXXX  XXX - with instructions 

MSA-1959

Consent for Sterilization

 

XXX 

MSA-1576  Complex Care Prior Approval-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  Hospital Newborn Notice  XXXX  XXX 
MSA-4114  CSHCS Medical Eligibility Report  XXXX  XXX 

MSA-4240

Certification for Induced Abortion

XXXX 

XXX 

MSA-115

Occupational Therapy - Physical Therapy - Speech Therapy Prior Approval Request/Authorization

XXXX 

XXX 

MSA-6544-B

Practitioner Special Services Prior-Approval - Request/Authorization

XXXX

XXX

MSA-204-HH Home Help Agency Caregiver Enrollment Authorization XXXX XXX
MSA-2081 Genetic and Molecular Laboratory Test Authorization Request 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