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                Get Mi Dch-1074 2011
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How to fill out the MI DCH-1074 online
The MI DCH-1074 form is essential for notifying the Michigan Department of Health and Human Services about a beneficiary’s hospice enrollment, update, or disenrollment. This guide provides clear, step-by-step instructions to help you complete the form accurately online.
Follow the steps to effectively complete the MI DCH-1074 form.
- Click the ‘Get Form’ button to obtain the MI DCH-1074 form and open it in the editor.
- Determine the purpose of the form by selecting either the Enrollment Application, Enrollment Update, or Disenrollment Notice at the top right corner.
- Enter the effective date for the selected action in the appropriate field.
- Complete Section I by providing the hospice provider information including the name, National Provider ID, provider addresses, and contact numbers.
- If the beneficiary is currently admitted to a nursing facility or ventilator dependent care unit, fill out Section II with the facility's name, address, and ID.
- In Section III, fill in the beneficiary's personal information, including their name, ID number, address, social security number, date of birth, and other relevant details.
- Use the remarks section to provide any additional explanations or information as needed.
- In Section V, ensure the beneficiary or their authorized representative signs and dates the form, and provide a witness signature if required.
- Finally, save your changes and download, print, or share the completed MI DCH-1074 form as needed.
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        Yes, you can request a Medicaid card online through the Michigan Department of Health and Human Services. This online service simplifies the process for you, allowing you to submit your request efficiently while ensuring your eligibility remains intact. Always keep your MI DCH-1074 form close as it may contain essential details needed for your application.
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