Get Mi Msa-2565-c 2015-2025

The MI MSA-2565-C is an important document required for admitting a beneficiary to a facility and ensuring their eligibility for Medicaid services. This guide provides clear and supportive instructions to assist you in completing the form correctly and efficiently.

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

1. Press the ‘Get Form’ button to access the MI MSA-2565-C form and open it in your editing tool.
2. Begin by filling in the patient's name in the designated field (Last, First, Middle). Ensure the name matches official documents.
3. Select the gender of the patient by marking the appropriate box for either Male (M) or Female (F).
4. Enter the patient’s birth date using the format MM/DD/YYYY.
5. Input the patient’s Social Security number in the provided field.
6. Fill in the home address of the patient, including street number, apartment number (if applicable), city, state, and ZIP code.
7. Provide the name of the person responsible for the patient (Last, First, Middle) and their relationship to the patient.
8. Enter the phone number of the person responsible and ensure it follows the format (XXX) XXX-XXXX.
9. Complete the provider details by entering the name, address, and contact information of the medical provider.
10. Check the type of facility where the patient is being admitted by selecting one option: Hospital, Nursing Facility, or other specified type.
11. Fill in the date of admission using the format MM/DD/YYYY.
12. If applicable, indicate the hospital case number and any specific patient status like admission likelihood or primary diagnosis.
13. Provide information regarding any Medicare or private health insurance coverage available to the patient.
14. Once all fields are filled, review the information for accuracy.
15. Finally, save the changes. You can download, print, or share the completed MI MSA-2565-C form as required.

Start filling out the MI MSA-2565-C form online today to ensure a smooth admission process.