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How to use or fill out MDHHS - Medicaid Provider Forms and Other Resources with DocHub
- 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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