Msa 4676-2026

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  1. Click ‘Get Form’ to open the msa 4676 in the editor.
  2. In Section I, enter the DHS Specialist's name, authorized rate, and patient details including their name, case number, and contact information.
  3. Proceed to Section II where the medical provider fills in their name, NPI number, and diagnosis. Indicate if special transportation is needed and whether someone will accompany the patient.
  4. In Section III, the transportation provider should complete their details including name and type of transportation. If applicable, list any additional expenses.
  5. For Section IV, document each appointment by entering the date, times, miles traveled, and signatures from all parties involved to confirm services were provided.
  6. Finally, Sections V and VI require calculations for payment authorization by the DHS Specialist and Manager. Ensure all signatures are obtained before submission.

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A caregiver background check gathers information about a candidates history, such as criminal records and previous work experience, to help employers decide whether the candidate is qualified and eligible for a caregiving position. Examples include: Home care aides. Personal care aides.
MI DHS-4574 is a form used by the Michigan Department of Health and Human Services (MDHHS) to collect information regarding an individuals eligibility and circumstances related to public assistance programs.
MDHHS services include: food assistance, cash assistance, child care, medical assistance, home weatherization, utility assistance, burial services, child support, foster care and adoption, abuse and neglect.

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How to Get Your Caregiver Certification Education and Training: Complete at least 75 hours of training, including classroom instruction and hands-on experience. Criminal Background Check: Pass a background check to ensure you can safely work with vulnerable populations.
You may be stopped from being a caregiver if you have a criminal record involving abuse, neglect, sexual abuse, fraud, or any violent crime. A failed background check, recent substance abuse, or being on a sex offender registry can also disqualify you.
The Home Help program is administered by the Michigan Department of Health and Human Services (MDHHS) and provides personal care services to individuals who need hands-on assistance with Activities of Daily Living (ADLs) and assistance with Instrumental Activities of Daily Living (IADLs).

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