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Click ‘Get Form’ to open the MSA-115 in our editor.
Begin by filling in Box 2-3 with the Medicaid enrolled provider’s name and National Provider Identifier (NPI). Ensure accuracy for smooth processing.
In Box 4-6, enter the provider’s telephone number, address, and fax number. This information is crucial for communication regarding your 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.
Proceed to fill out Boxes 12-23 with diagnosis codes, treatment goals, and progress summaries. Make sure goals are measurable and clearly defined.
Finally, ensure that all required signatures are obtained in Boxes 29 and 30 before submitting your form via mail or fax as instructed.
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a readiness guide for state and local public benefits agencies
In 2018, the MDHHS launched a redesigned benefits application which integrated the states largest public assistance programsincluding healthcare, foodRead more
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