Get Mi Choice Waiver Disenrollment Notification ... - State Of Michigan - Michigan

This guide provides step-by-step instructions on how to fill out the Mi Choice Waiver Disenrollment Notification form accurately and efficiently. Whether you are a waiver agency representative or need to assist someone, this comprehensive guide ensures clarity throughout the process.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Select the waiver agency name from the provided options. It is important to ensure that the correct agency is selected to prevent any issues with processing.
3. Enter the Medicaid Provider ID Number in the specified field, which verifies the agency's eligibility.
4. Fill in the contact information, including the phone number and contact person's name. This information will facilitate communication if any follow-up is needed.
5. For participant information, input the participant's first name, last name, and complete address. If the address has changed, check the corresponding box.
6. Include the participant's Medicaid ID Number and phone number to ensure accurate identification.
7. In the disenrollment information section, provide the MI Choice stop/LOC 22 end date, followed by selecting the reason for disenrollment from the options given.
8. If applicable, fill in the date of death, nursing home admission date, name and address of the nursing home, or reason for non-eligibility. Ensure accuracy in this information as it is essential for record-keeping.
9. Certify the accuracy of the provided information by signing the form as a waiver agency representative.
10. Select the appropriate DHS county office and document the date of DHS office notification along with the method of submission (email, fax, phone call, etc.).
11. After filling out all fields, review the form for completeness and accuracy. Finally, make sure to save changes, download, print, or share the form as needed.

Complete your documents online to ensure timely processing.