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DHS-4574, Application for Health Care Coverage …

DHS-4574 (Rev. 5-16) Previous edition FOR Health CARE Coverage PATIENT OF NURSING FACILITYM ichigan Department of Health and Human ServicesFOR OFFICE USE ONLYB eneficiary NameClient IDCase NumberHELP IS AVAILABLEC ountyDistrictSectionUnitSpecialistThe Michigan Department of Health and Human Services must help all persons fill out the Application , when requested. If you need help, please call or visit your specialist or the office named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice.

DHS-57 (Rev. 5-16) Previous edition obsolete. APPLICATION FOR HEALTH CARE COVERAGE PATIENT OF NURSING FACILITY Michigan Department of …

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