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Strictly Confidential MANAGED HEALTH CARE SERVICES INCORPORATED PRIOR AUTHORIZATION PA FORM Please Fax form to 1-902-481-7114 or Mail to MHCSI 201 Brownlow Avenue Unit 20 Dartmouth NS B3B 1W2 TO BE COMPLETED BY EMPLOYEE PATIENT INFORMATION Surname First Name Initial Employee Name if not patient Group ID Relationship W EMPLOYEE W SPOUSE W DEPENDENT Patient date of birth Coordination of benefits W NO W YES If yes Name of Coordinating Plan If MHCSI please provide Street Address City Province...
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What is mhcsi form?
The mhcsi form is a document used to report certain health coverage information to the IRS.
Who is required to file mhcsi form?
Health insurance providers or sponsors of self-insured health plans are required to file the mhcsi form.
How to fill out mhcsi form?
The mhcsi form can be filled out electronically or on paper. It requires providing specific information about the health coverage, including the names and taxpayer identification numbers of individuals covered.
What is the purpose of mhcsi form?
The purpose of the mhcsi form is to provide the IRS with information about individuals who have minimum essential health coverage.
What information must be reported on mhcsi form?
The mhcsi form requires reporting information such as the names, addresses, and taxpayer identification numbers of individuals covered, as well as the months of coverage.
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