Get Mi Msa-1680-b 2021-2026

The MI MSA-1680-B form is essential for obtaining prior authorization for dental services under Michigan Medicaid. This guide will walk you through the process of filling out the form online in a clear and user-friendly way.

Follow the steps to complete the MI MSA-1680-B form online.

1. Click the ‘Get Form’ button to access the MI MSA-1680-B and open it in the online editor.
2. Begin by entering the prior authorization number in the designated field at the top of the form. This number is for MDHHS use only.
3. Fill in the provider's name, including the last name, first name, and middle initial.
4. Provide the provider's street address, city, state, and ZIP code accurately.
5. Input the provider's fax number and phone number exactly as it appears, ensuring no errors.
6. Enter the provider's National Provider Identifier (NPI) number in the specified field.
7. In the beneficiary section, write the beneficiary's name, date of birth, sex, and MI Health Card number.
8. Document whether radiographs are attached. If yes, indicate the number of radiographs and the date they were taken.
9. Complete the treatment details by indicating if treatment is for orthodontics and if a treatment plan is included.
10. Mark the missing teeth on the diagram provided, using an 'X' for those missing and a '/' for those to be extracted.
11. Specify the status of the current prosthesis and provide details regarding its wear and repairs.
12. Fill out any additional pertinent dental or medical history that may affect the treatment.
13. Sign and date the form in the provider certification section, ensuring the signature is the provider's printed name, as required.
14. Once all sections are completed, review the form for accuracy, then save changes, download, print, or share as needed.

Start filling out the MI MSA-1680-B online today to ensure timely authorization for dental services.