Care Recipient Forms
If you or a loved one needs assistance with daily living activities, these forms are the first step toward receiving Home Help services through Michigan Medicaid. The forms below help determine eligibility, document medical need, and establish your Home Help services. Download and complete each applicable form, then submit it securely using our dropbox below when finished.
Navigate to the Submit Forms tab to see the different methods you can use to complete the forms. Need assistance? Our team is happy to help guide you through the process.
Begin Your Home Care Journey
DHS-390 is the first step toward receiving Home Help services through Michigan Medicaid. This form helps determine eligibility for services that support safe, independent living at home.
Verifying Your Care Needs
MDHHS-6200 is completed by your healthcare provider to document the medical need for in-home care services. It helps determine what level of support may be appropriate for your situation. The medical provider’s signature must be in ink.
Creating Your Care Plan
MSA-4676 outlines the services, schedule, and responsibilities between the care recipient and caregiver. It helps ensure everyone understands the care being provided and the expectations moving forward.
Family Caregiver Tax Exemption
DHS-4771: Certain family caregivers may qualify for an exemption from Social Security and Medicare (FICA) payroll taxes. Complete this form if you believe you may qualify for this benefit.