Get Mi Msa-1656 2015-2025

The MI MSA-1656 form is crucial for obtaining prior authorization for complex seating systems and mobility devices. Completing this form online involves several steps, ensuring that all necessary information is accurately provided by a licensed medical professional.

Follow the steps to successfully complete the MI MSA-1656 online.

1. Click the ‘Get Form’ button to access the MI MSA-1656 online form and open it in your browser.
2. Begin by filling out the beneficiary information in Section 1. This includes the beneficiary's name, date of birth, sex, mihealth number, and details about the ordering physician and their specialty. Ensure the beneficiary name and mihealth number are also entered at the top of each page.
3. Proceed to Section 2 and document the medical history of the beneficiary. Provide the primary and secondary diagnoses, onset dates, and any details regarding previous surgeries relevant to the mobility device request. If weight cannot be measured, provide an estimate.
4. In Section 3, focus on the home environment. Indicate the type of residence (house, apartment, assisted living) and whether the beneficiary lives alone. Provide details on caregiving support if applicable.
5. Complete Section 4 by detailing the beneficiary's transportation methods. Note if the current or requested mobility equipment fits in the vehicle used for transportation.
6. Section 5 requires information on pressure relief needs. If there are current decubiti, specify their stage according to the National Pressure Ulcer Advisory Panel classification.
7. In Section 6, describe the functional abilities of the beneficiary without mobility devices. This includes evaluations of sitting, standing, ambulation, and transfers.
8. Complete Section 7 with the Modified Ashworth Scale and Manual Muscle Evaluations information. Measurements and observations related to muscle tone and condition should be documented accurately.
9. Section 8 focuses on mobility goals. Check all applicable goals and provide additional comments to support the medical necessity of the requested equipment.
10. In Section 9, list all equipment currently owned or used by the beneficiary, including brand, model, serial number, and description.
11. For beneficiaries in nursing facilities, Section 10 must be completed by the Nursing Facility Director or ordering physician.
12. Finally, Section 11 is for evaluator attestation. This must be signed by the evaluator, confirming the accuracy and truthfulness of the provided information. Enter the evaluation date, evaluator information, and signature.
13. Once all sections are completed, review the entire document for accuracy. Save changes, and prepare to submit the form alongside any required addendums to the Michigan Department of Health and Human Services.

Start filling out the MI MSA-1656 online today to ensure timely processing of your request.