Completion Instructions for MSA-115 - michigan 2026

1. Click ‘Get Form’ to open the MSA-115 in the editor.
2. Begin by filling out Box 2-3 with the Medicaid enrolled provider’s name and National Provider Identifier (NPI). Ensure accuracy as this information is crucial for processing.
3. In Box 4-6, enter the provider’s telephone number, address, and fax number. This contact information should be current to avoid any delays.
4. For Boxes 7-10, input the beneficiary’s name, sex, mihealth card number, and birth date. Verify these details against the mihealth card for correctness.
5. Continue filling out Boxes 11-23 with relevant medical information including diagnosis codes, treatment goals, and progress summaries. Each entry should reflect accurate and measurable data.
6. Complete Boxes 24-30 regarding therapy services and ensure all required signatures are obtained before submission.

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