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AUTHORITY Title V and Title XIX of the Social Security Act. COMPLETION Is voluntary. DCH-0078 12-14 Previous editions are obsolete. Michigan Department of Community Health Completion Instructions for DCH-0078 Request to Add Terminate or Change Other Insurance Form DCH-0078 is a formal request for change in other insurance status and must be submitted by the Medicaid provider Medicaid Health Plan Local Health Department or the Department of Human .

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Tell you which doctors, pharmacies and hospitals are part of each Medicaid health plan. Answer general questions you may have about Medicaid benefits. Enroll you in the Medicaid Health Plan you choose. For more information, call Michigan ENROLLS at 1-888-367-6557.

A Michigan Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug prescription in the state of Michigan. In this form, the physician provides their clinical reasoning for making this request instead of prescribing a drug from the Preferred Drug List (PDL).

If you think your drug may require a prior authorization, call your insurer directly to confirm.

To add, terminate or change other insurance on-line, visit https://.Michigan.gov/ReportTPL to access the form and instructions. Allow 7-10 business days for the request to be completed.

Then, select the Prior Authorization and Notification tool on your Link dashboard. Or, call 888-397-8129.

Medicaid requires prior authorization (PA) to cover certain services before those services are rendered to the beneficiary. The purpose of PA is to review the medical need for certain services. It does not serve as an authorization of fees or beneficiary eligibility.

Please contact your MDHHS caseworker if your name and/or address have changed. Report NAME CHANGES and ADDRESS CHANGES to your MDHHS caseworker. A mihealth card can not be issued until these changes are reported to your MDHHS worker.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Dch 0078 Form
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2022 MI DCH-0078
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