Get Msa0732 Form

The Msa0732 Form is essential for requesting prior authorization for private duty nursing services for Medicaid beneficiaries. This guide provides step-by-step instructions for filling out the form online with clarity and support.

Follow the steps to complete the Msa0732 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online tool for filling out the document.
2. Complete the Prior Authorization Number field, which is designated for use by the Michigan Department of Community Health.
3. Enter the provider's information, including the agency name or the name of the individual, their designation as RN or LPN, NPI number, phone number, address, and fax number.
4. Fill in the beneficiary's personal information: their complete name, birth date, sex, MIHealth card number, address, county, and primary diagnosis with the appropriate ICD code.
5. If there is other insurance, provide the company name along with the group/policy and certificate/contract numbers.
6. If the beneficiary is currently hospitalized, supply the hospital's address and phone number, as well as the anticipated discharge date and the name and contact details of the Discharge Planner.
7. Provide the ordering physician's details, including their name, NPI number, phone number, address, and fax number.
8. Describe the service(s) being requested, including procedure codes and total hours required to provide the services, along with expected start and end dates, if known.
9. Fill out the home environment section detailing the number of siblings living in the home, whether they receive PDN, names, and MIHealth card numbers if applicable, and the number of other individuals in need of care.
10. If the beneficiary is in school, provide their school information, including hours per day and week they will be attending school.
11. If multiple PDNs or agencies are involved, list their names, phone numbers, fax numbers and indicate which provider will manage the care plan.
12. Sign to certify the accuracy of the information and understanding of the necessity for prior authorization for the services requested.
13. After completing all sections, save the document, download, print, or share the form as required for submission.

Complete your Msa0732 Form online today for swift processing of your private duty nursing services request.