Get Mdch Com

Filling out the Mdch Com online form is a crucial step for applicants seeking assistance with medication through the Michigan Drug Assistance Program. This guide provides clear and actionable steps to ensure successful completion of the form.

Follow the steps to successfully complete the Mdch Com online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the first section, enter your MIDAP subscriber number if applicable, followed by your name, including last name, first name, and middle initial, on the designated lines.
3. Fill in your address, city, state, zip code, and county in the respective fields provided.
4. Input your phone number, social security number, and date of birth in the specified spaces.
5. Indicate your gender by marking the appropriate checkbox.
6. Select your race/ethnicity by checking the relevant options from the list provided.
7. Respond to the question about Michigan residency by checking ‘YES’ or ‘NO’ as applicable.
8. Indicate whether you have Medicare by selecting ‘YES’ or ‘NO’.
9. List all requested medications clearly in the designated space.
10. Provide a reason for your request in the specified area.
11. The case manager must print their name, agency, phone number, and provide a signature along with the date to confirm eligibility.
12. The applicant must sign and date the authorization, allowing the Michigan Department of Community Health to access relevant medical information.
13. Once all information is filled out, verify that it is complete, then follow the instructions to send the form via fax to the MIDAP office at 517-335-7723.
14. After submission, retain a copy for your records and be aware that coverage approval will determine the issuance of a subscriber card.

Start filling out your Mdch Com form online today to ensure you receive the assistance you need.