Michigan Department of Community Health Document Number MEDICAL TRANSPORTATION STATEMENT Only ONE medical provider and ONE transporter per form. See Page 2 for Instructions Copy Distribution PA 431 and Non-Discrimination Information. SECTION I - DHS Specialist Completes DHS Specialist Name Authorized Rate Standard Special Patient/ Beneficiary Name DHS Case No. CO MA-TOA Level of Care Code Beneficiary ID No. Patient/Bene. PDT Bank ID No. Amount D.
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How to fill out the Msa 4676 Form online
Filling out the Msa 4676 Form online can streamline the process of documenting medical transportation services. This guide provides a step-by-step approach to ensure that you complete the form accurately and efficiently, catering to a wide range of users.
Follow the steps to complete the Msa 4676 Form online
- Click the ‘Get Form’ button to access the Msa 4676 Form and open it in the designated online editor.
- In Section I, provide the required information for the DHS specialist, including the specialist's name, phone number, and details about the patient or beneficiary, such as their name and DHS case number.
- Proceed to Section II where the medical provider must fill in their details. Include the medical provider's name, NPI number, and diagnosis information. Indicate if the patient requires special transportation or if an overnight stay is needed.
- In Section III, the transportation provider will complete their section, including their name and complete address. They should also specify the type of transportation and any other related expenses.
- Section IV requires records of transportation for each visit. Fill in the date, departure time, return time, round-trip miles, and other expenses, ensuring each relevant party signs the form to verify the transportation services.
- In Section V, the local DHS specialist and manager will calculate and authorize the payment based on the information provided. Ensure they sign and date the form.
- Complete Section VI as needed for local DHS accounting purposes. Make sure all necessary signatures and dates are included before proceeding.
- Finally, save your changes, download the completed form, or print it as required. Share it with relevant parties as needed.
Complete your Msa 4676 Form online today for a smoother documentation process.
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