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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

BPHASA-2207 Home Help Billing for Hospital Admission Date XXXX XXX
HASA-2104 Home Help Agency Provider Employment Requirements XXXX XXX
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 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