
Structions, Copy Distribution, PA 431 and Non-Discrimination Information. SECTION I - DHS Specialist Completes: DHS Specialist Name Phone No. ( DHS Case Number MA-TOA Authorized Rate Standard Special ) CO # DIST # Patient/ Beneficiary Name Beneficiary ID No. Address (No. & Street, City, State, ZIP Code) SECTION II - Medical Provider Completes: Medical Provider's Name NPI Number Chronic, ongoing illness? (This usually means monthly ongoing care, but may include less than monthly car.
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How to fill out the MI MSA-4674A online
The MI MSA-4674A is an essential form for documenting medical transportation requests for individuals who require ongoing treatment. This guide provides clear, step-by-step instructions for completing the form online, ensuring a smooth submission process.
Follow the steps to complete the MI MSA-4674A online.
- Click ‘Get Form’ button to obtain the MI MSA-4674A and open it in the editor.
- In Section I, the DHS Specialist will fill in their name, phone number, case number, and authorized rate. Ensure that this information is accurate as it is crucial for processing your request.
- In Section II, the medical provider will complete their name, NPI number, and provide information regarding the patient's ongoing medical needs. They will also need to indicate if an overnight stay is required and whether special transportation is necessary.
- Section III must be filled out by the transportation provider. This includes the provider's name, type of transportation, and any additional expenses incurred. The provider should also ensure that their contact information is complete.
- In Section IV, list all appointment dates and record round-trip mileage and attendant fees for transportation. Each date needs to be signed by the medical provider, transporter, and beneficiary to certify the services provided.
- Section V involves the DHS Specialist and manager calculating and authorizing payment for services. This is a crucial step for ensuring that the transportation costs are approved.
- Finally, review all sections for accuracy, and once confirmed, save changes, download, or share the completed form as required.
Complete your MI MSA-4674A form online to ensure timely processing of your medical transportation request.
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To fill out a medical authorization form, begin with your essential personal details, then specify what medical information you want to authorize and who can access it. It’s important to check all required fields and any additional notes about the authorization duration. This process follows the guidelines established in MI MSA-4674A, ensuring that your preferences are clear and manageable.
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