Get Msa 10 21 Form

Completing the Msa 10 21 Form online is a crucial step for providers of home help services in Michigan. This guide will provide you with clear instructions to navigate through each section of the form effectively, ensuring you meet all requirements for Medicaid services.

Follow the steps to fill out the Msa 10 21 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information. If you are an individual home help provider, fill in your name, Social Security Number, and date of birth. Make sure to format your date as MM/DD/YYYY.
3. Provide your residential address, including street number, street name, and, if applicable, apartment or lot number.
4. Enter the current telephone number and, if desired, your email address for future communication.
5. If applicable, supply your Post Office Box number along with the city, state, and zip code of your residence.
6. For agency providers, start by entering the complete name of your agency followed by the IRS Tax ID number.
7. Fill out the address of the agency, including street number, unit number, city, state, and zip code.
8. Provide the agency telephone number along with the contact person's name and their email address.
9. Both individual and agency providers must disclose any criminal convictions related to Medicaid and provide details in the specified section.
10. Re-enter the Social Security Number or IRS Tax ID number as required.
11. Review the agreement terms and conditions, then check the appropriate box to indicate your compliance.
12. Once all information is completed and verified, save your changes, and proceed to download, print, or share the completed form as needed.

Ensure you fill out the Msa 10 21 Form online accurately to maintain your eligibility for Medicaid services.