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Get Mi Msa-1680-b 2014
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How to fill out the MI MSA-1680-B online
The MI MSA-1680-B form is essential for obtaining prior authorization for dental services covered by Medicaid. This guide provides users with clear, step-by-step instructions to help complete the form accurately and efficiently.
Follow the steps to complete the MI MSA-1680-B online.
- Press the ‘Get Form’ button to access the MI MSA-1680-B and open it in the form editor.
- Begin by filling out the provider information in section 2, including the provider's name, address, NPI number, and contact information.
- In section 9, enter the beneficiary's full name and date of birth, ensuring accurate details.
- Indicate the beneficiary's health card number in section 12 along with their sex in section 11.
- Complete sections regarding any existing dental plans or treatments, specifically addressing questions about nursing home residence and covering any previous treatments.
- In sections 16 and 17, provide the beneficiary’s qualifying diagnosis using appropriate ICD codes.
- If applicable, indicate whether x-rays are enclosed and provide details in sections 18 and 19 regarding orthodontics.
- Complete treatment details by marking missing teeth and specifying any proposed treatments in sections 22 to 30.
- Sign and date the form in section 31 to certify the correctness of the information provided.
- After reviewing all entries, save your changes. You can then download, print, or share the completed MSA-1680-B form as needed.
Complete the MI MSA-1680-B online today to ensure timely authorization for dental services.
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To get a new Michigan Medicaid card, you can apply through the MiBridges portal. If your situation has changed, ensure you update your information to reflect your current needs. This will help in obtaining your MI MSA-1680-B card smoothly.
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