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Get Mi Msa-4240 2016-2025
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How to fill out the MI MSA-4240 online
The MI MSA-4240 form is essential for obtaining Medicaid, Healthy Michigan Plan, or MIChild payments for abortion services under specific circumstances. This guide provides clear instructions for filling out the form accurately and efficiently.
Follow the steps to complete the MI MSA-4240 form online.
- Click the ‘Get Form’ button to access the MI MSA-4240 and open it for editing.
- Enter the beneficiary's full name in the designated field. Ensure that the name is spelled correctly to avoid processing delays.
- Provide the beneficiary's mihealth number in the respective section to link the form to their Medicaid account.
- Fill in the date of service when the abortion procedure is performed. This information is crucial for claim processing.
- Input the complete address of the beneficiary, including street number, apartment or lot number, city, state, and ZIP code.
- Select the appropriate box to indicate the reason for the abortion service: whether it is to save the mother’s life or due to rape or incest.
- If applicable, list the medical conditions that necessitate the abortion in the space provided.
- Answer the question regarding the filing of a police report for cases of rape or incest by marking 'YES' or 'NO'. If you select 'NO', provide an explanation in the space provided.
- Indicate whether a report was filed with the local Michigan Department of Health and Human Services office, similarly marking 'YES' or 'NO' and providing an explanation if necessary.
- The physician must complete the form by typing or printing their name, signing by hand, and including their address, city, state, ZIP code, and provider NPI number.
- Review all entries for accuracy. After ensuring everything is correct, save changes to the form. Users can also download, print, or share the completed document as needed.
Complete your MI MSA-4240 form online today to ensure timely processing of your request.
Abortions are only covered by Medicaid in Michigan under certain conditions outlined in the MI MSA-4240 program guidelines. Coverage typically applies if the abortion is necessary for the mother's health or safety, or in cases of rape or incest. To navigate these complexities effectively, consider using platforms like uslegalforms to guide you through the process and understand your rights.
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