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Click ‘Get Form’ to open the MSA-115 in the editor.
Begin by filling in Box 2-3 with the Medicaid enrolled provider’s name and NPI number. Ensure accuracy as this information is crucial for processing.
In Box 4-6, enter the provider’s telephone number, address, and fax number. This contact information is essential for communication regarding the authorization request.
Complete Boxes 7-10 with the beneficiary’s details: name, sex, mihealth card number, and birth date. Verify this information against the mihealth card for accuracy.
Proceed to fill out Boxes 11-23, detailing admission dates, diagnosis codes, treatment goals, and progress summaries. Each entry should reflect accurate clinical data to support your request.
Finally, ensure that Boxes 30 and 31 are signed by both the prescribing practitioner and therapist. Unsigned forms will be returned for completion.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (105 Votes)
2015	4 Satisfied (30 Votes)
2012	4.4 Satisfied (308 Votes)
2009	4.2 Satisfied (60 Votes)

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