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Get MI MSA-0006 2018-2024

Formation requested may confirm this case can be closed. Provide a copy of the deceased Medicaid member's death certificate and any other documentation requested on this form. Mail completed form and all requested documentation in the enclosed (postage paid) envelope provided to: Michigan Department of Health and Human Services Third Party Liability P.O. Box 30435 Lansing, Michigan 48909 If you have any questions about how to complete this form, you may call the TPL Division toll-free at 1-844-.

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