Form Msa 4674 – Fill Out and Use This PDF

Michigan Department of Community Health	Document Number

MEDICAL TRANSPORTATION STATEMENT

•Only ONE medical provider and ONE transporter per form.

•See Page 2 for Instructions, Copy Distribution, PA 431 and Non-Discrimination Information.

SECTION I - DHS Specialist Completes:

DHS Specialist Name

Authorized Rate

DHS Specialist Phone No.

Level of Care Code

Standard

Special

(

)

Patient/ Beneficiary Name

Beneficiary ID No.

Patient/ Beneficiary Street Address

Patient/Bene. Phone #

(

)

DHS Case No.

Prog. Code

CO #

DIST #

SEC

UNIT

DHS SPEC

City

State

ZIP Code

SECTION II - Medical Provider Completes:

Medical Provider's Name (MD, DO, DDS)

NPI Number

Address (No., Street, Bldg., Suite, etc.)

Provider's Phone No.

(

)

Diagnosis(es)

City

State

ZIP Code

Chronic, ongoing illness?

Is overnight

Was patient

Name of Referring Physician

YES

YES

YES

(This usually means monthly ongoing

stay required?

referred to you?

NO

NO

NO

care, but may include less than

monthly care.)

Does someone need to

If YES, Who & Why

Is special

Type (Van w/ wheelchair lift, etc.)

YES

YES

accompany the patient to

transportation

NO

NO

the medical appointment?

needed?

SECTION III - Transportation Provider Completes:

Transportation Provider's Name (Last, First)

Soc. Sec. No. or ID No.

Type of Transportation

Other Expenses (Parking Receipts, etc.)

Transportation Provider's Complete Address (No. & Street, City, State, ZIP Code)

Phone No.

(

)

SECTION IV - Transportation Record (Provider / Transporter / Beneficiary Sign for EACH Visit):

SECTION V - Local DHS Specialist & Manager Complete:

SECTION VI - Local DHS Accounting Use Only:

Audited and Approved by:			Date	Doc. Type	Intf. Type	PDT	Bank ID No.	DMI
Appr. Yr.	Index	PCA		Agency Object Code			Amount
							$
NIGP Code	MAIN/LOAAS Doc. No.	Check No. & Date		LOAAS Account No.

Page 1 of 2

MSA-4674 (03/14) Previous editions are obsolete.

Instructions for MSA-4674

(Medical Transportation Statement)

GENERAL INSTRUCTIONS:

•Use one form per month for each medical provider or transporter.

•Use this form for 5 or less trips made in a calendar month.

•This form must be returned to the local Michigan Department of Human Services local office within 90 calendar days from the date of service to authorize payment for medical transportation.

COMPLETION INSTRUCTIONS:

SECTION I:

•The DHS Specialist completes this section.

SECTION II:

•The medical provider completes this section. (Only one medical provider per form.)

•Diagnosis is not required if a DHS-54A was completed in the past year.

SECTION III:

•The transportation provider completes this section.

•Use only ONE transporter per form.

•Leave this section BLANK if the beneficiary drives themselves OR if the beneficiary wishes to receive the transportation payment directly.

SECTION IV - Transportation Record:

Transporter:

•Enter the following for each appointment/visit: date, departure time, return time, number of miles traveled (round trip) and the attendant fee if medically authorized.

•Sign EACH appointment line. This verifies that transportation services were provided on that date.

•If SECTION III was completed, then only that transporter may sign in this section.

Medical Provider (or their staff):

•Confirm the date(s) of appointment(s) and sign your name to verify that the medical visit did occur.

Patient/Beneficiary:

•Sign each appointment line even if you transported yourself. This is also used to verify that each medical appointment was kept and that transportation services were provided.

SECTION V:

•The DHS Specialist calculates the transportation payment and signs their name and dates.

•The DHS Manager reviews the entire form and signs their name approving the payment.

•The local office must then approve the MSA-4674 and submit it to the appropriate DHS Accounting Service Center within 10 business days of receipt of the form.

SECTION VI:

•The local DHS Accounting Unit completes this section.

COPY DISTRIBUTION:

Page 2 of 2

MSA-4674 (03/14) Previous editions are obsolete.