Get Mi Dch-1074 2015-2025

The MI DCH-1074 form is essential for documenting hospice enrollment with the Michigan Department of Health and Human Services. Completing this form accurately ensures that beneficiaries receive the required hospice services in a timely manner.

Follow the steps to complete the MI DCH-1074 efficiently.

1. Click ‘Get Form’ button to obtain the DCH-1074 form and open it in your preferred online platform.
2. Indicate the purpose of the form by selecting the appropriate box at the top right corner. Choose between enrollment application, enrollment update, or disenrollment notice and enter the corresponding effective date.
3. Complete the provider information section with the hospice provider name, national provider ID, provider ID, fax number, and address. Ensure all details are accurate.
4. If applicable, indicate whether the beneficiary is in a nursing facility or ventilator dependent care unit by completing Section II. Provide the facility's name, address, and relevant identification numbers.
5. Fill out Section III with the beneficiary's personal information, including their name, Medicaid ID number, social security number, address, date of birth, gender, and home phone number.
6. In Section IV, use the remarks section to clarify additional information relevant to the beneficiary's case, such as prior hospice enrollment or special healthcare services.
7. Review Section V to ensure the beneficiary or authorized representative understands all conditions of enrollment. Secure necessary signatures as required.
8. Once the form is complete, verify that all fields are filled, save changes, and prepare to submit the form. You can download, print, or share the completed DCH-1074.

Begin filing the MI DCH-1074 online today to ensure timely access to hospice services.