Get Mi Msa-2565-c 2014

The MI MSA-2565-C form is crucial for notifying about the admission of a beneficiary to a healthcare facility. This guide will provide you with a straightforward and supportive approach to completing this form online, ensuring all necessary information is accurately captured.

Follow the steps to successfully fill out the MI MSA-2565-C online.

1. Click the ‘Get Form’ button to access the MI MSA-2565-C and open it in the online editor.
2. Begin by entering the patient's full name in the designated fields for Last, First, and Middle names.
3. Indicate the patient's gender by selecting either 'M' for male or 'F' for female.
4. Fill in the patient's birth date in the format of MM/DD/YYYY.
5. Provide the patient's Social Security number in the specified field.
6. Enter the home address, including the street number and apartment information, in the corresponding section.
7. List the name of the person responsible for the patient, along with their home address and phone number.
8. Fill in the provider's name and address, as well as their National Provider ID and Provider ID numbers.
9. Specify the attending physician's name for medical oversight.
10. Select the type of facility by marking the applicable option such as hospital, nursing facility, or other.
11. Indicate the date of admission in the format of MM/DD/YYYY.
12. Check the box to indicate if the admission is likely to last 30 days or longer and provide an estimated length of stay if applicable.
13. Detail the patient's primary and secondary diagnoses in the provided sections.
14. Identify where the patient was admitted from by checking the appropriate location.
15. Disclose any Medicare or private health insurance coverage available, and complete the related items as necessary.
16. Complete the patient certification section by having the patient or their representative sign and date the form.
17. Ensure that all sections are completed before saving changes to your form. You can then download, print, or share the completed MI MSA-2565-C.

Complete your MI MSA-2565-C form online today to ensure a smooth admission process.