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DSH feedback form - Michigan Health Hospital Association - mha 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your hospital's Medicare number in the designated field at the top of the form.
- In the 'Hospital Name' section, clearly write the full name of your hospital.
- Proceed to Section 1. If your hospital chooses to decline FY 2015 Medicaid DSH, check the box provided. Remember, this decision is irrevocable and will affect future eligibility.
- If you are opting to reduce your DSH limit, move to Section 2. Fill in the Initial DSH Calculation amount in field (a), then specify the reduction amount in field (b). The reduced limit will automatically calculate in field (c).
- Finally, complete Section 3 by providing the name and signature of an authorized hospital staff member along with the date.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2015 | 4.8 Satisfied (101 Votes) |
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medicare services
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