MSA-0732. Private Duty Nursing Prior Approval - Request - michigan-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Prior Authorization Number, which is for MDHHS use only.
3. Indicate whether this request is an initial or renewal by checking the appropriate box. If it's a renewal, specify if you are increasing or decreasing units.
4. Fill in the PDN provider information, including agency name or individual’s name, NPI number, phone number, address, and fax number.
5. Provide beneficiary information such as their full name, birth date, sex, mihealth card number, complete address, county, and primary diagnosis using the correct ICD code.
6. If applicable, include other insurance details like company name and policy numbers.
7. Complete hospital information if the beneficiary is currently hospitalized; include facility details and anticipated discharge date.
8. List ordering physician information with their complete name, NPI number, contact details.
9. Describe the services to be provided using HCPCS codes and indicate total units required per month along with start and end dates if known.
10. Provide home environment details including siblings in the home and any other individuals requiring care.
11. Ensure all signatures are completed at the end of the form to certify accuracy before submission.

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