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Get MI MSA-115 2012

5 must be used by Medicaid enrolled outpatient hospitals, outpatient therapy providers, nursing facilities and home health agencies to request Prior Authorization (PA) for therapy services. MDCH requests that the MSA-115 be typewritten to facilitate processing. Fill-in enabled copies of this form can be downloaded from the Michigan Department of Community Heath (MDCH) website www.michigan.gov/medicaidproviders >> Policy and Forms >> Forms. The request for PA must be complete and of adequate clar.

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