MDCH - Medicaid Provider Forms and Other Resources

Medicaid Provider Forms and Other Resources

Agency: Community Health

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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Right click on the link and choose "Save Target As". When prompted for the location of the save, remove the .zip from the filename and replace with the .docx extension, then Save. This will keep it from being saved as a .zip file.

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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 Primary Referral Notification/Request	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