MI DHS-4574 2011 free printable template

FOR OFFICE USE ONLY Grantee Name MEDICAID APPLICATION Patient of Nursing Facility State of Michigan Department of Human Services Grantee Client ID Case Number HELP IS AVAILABLE County District Section

Medical Assistance and Other Assistance Programs Medical Assistance and Other Assistance Programs The Michigan Department of Human Services provides an array of various financial assistance and other benefits to help those who qualify for these programs. The information below provides general information about each program as well as links to further information on each benefit. Referrals to the medical assistance program may be obtained to help pay for medical bills, or may provide a wide variety of other assistance. The Michigan Department of Human Services does not offer medical advice. The information below provides general information about any medical assistance, other assistance, or financial assistance program. For further information, please visit the Michigan Department of Human Services website, contact phone number or mail address listed below: Michigan Department of Health and Human Services Medical Assistance Program 111 East Capitol St. Saginaw, MI 48 Toll Free TTY: Michigan Department of Human Services HUMAN SERVICES — FINANCIAL ASSISTANCE — Other Assistance TTY: Michigan Department of Health and Human Services HUMAN SERVICES — FINANCIAL ASSISTANCE — Other Assistance TTY: Michigan Department of Human Services Treatment for Seniors Treatment for Seniors The Michigan Department of Human Services offers financial assistance to qualified patients of nursing facilities and those who require other medical treatment after a long-term illness, injury or disability. The patient's case is evaluated and determined by the treating facility. The person will be sent a form signed by the physician, physician assistant or advanced practice registered nurse authorizing payment for the treatment and the patient's medical care. Referrals to a treatment for seniors program may be obtained to help pay for medical bills, provide medical supplies and equipment and pay for living expenses. The Michigan Department of Human Services does not offer medical advice. Referrals to the treatment for seniors program may be obtained to help pay for medical bills, provide medical supplies and equipment and pay for living expenses. The Michigan Department of Human Services does not offer medical advice. If the patient needs additional medical care, the case should be referred to a Michigan health care provider.

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