Get Mi Msa-0838 2021-2025

The MI MSA-0838 form, also known as the authorization to disclose protected health information, is a crucial document for individuals seeking coverage under Michigan's Children's Special Health Care Services (CSHCS). This guide provides clear, step-by-step instructions on how to fill out the form online, ensuring that all necessary information is accurately provided.

Follow the steps to complete the MI MSA-0838 form online

1. Press the ‘Get Form’ button to access the MI MSA-0838 form in the online editor.
2. Begin by filling in the patient’s name and date of birth in the designated fields. Ensure that all details are spelled correctly.
3. Enter the full patient address including the number and street, city, state, and ZIP code.
4. Provide the CSHCS/Medicaid ID number, which is essential for processing the request.
5. Fill in the name of the parent or guardian responsible for the patient and their contact number.
6. If the parent or guardian’s address differs from that of the patient, complete the appropriate fields with their address information.
7. In the section requesting authorization, write the name of the specialty doctor, hospital, or clinic that will release the medical information.
8. Complete the full address of the selected specialty doctor, hospital, or clinic.
9. Review the authorization statements regarding the release of information for program eligibility and ensure you understand them before proceeding.
10. Sign the form as either the patient, parent, or legal guardian in the designated area.
11. Include the date on which the form is signed.
12. A witness signature is required; ensure an adult over the age of 18 signs and dates the form to validate it.
13. Once all fields are properly filled, save your changes, and prepare to download, print, or share the completed form as needed.

Complete your MI MSA-0838 form online today to ensure timely processing of your health care coverage.