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- Click ‘Get Form’ to open the MSA-1680-B in our editor.
- Begin by filling in the provider's information, including name, address, and contact details. Ensure accuracy as this information is crucial for processing.
- Next, enter the beneficiary's details such as name, birth date, and MI Health Card number. This section is vital for identifying the patient.
- Indicate whether the patient lives in a nursing home and if they are covered by any other dental plan. This helps determine eligibility for services.
- Complete the CSHCS diagnosis section with appropriate ICD codes and descriptions. This is essential for authorization of specific treatments.
- If applicable, indicate if x-rays are enclosed and provide treatment plans for orthodontics or prosthesis placements.
- Finally, review all entries for completeness and accuracy before signing the certification at the bottom of the form.
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