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1656 Form 2015-2023
Addendum(s) must accompany the MSA-1656 & MSA-1653-D.
BENEFICIARY INFORMATION: Complete beneficiary name, date of birth, sex, mihealth number, ordering
physician and physician specialty. The beneficiary name and mihealth number must be entered at the top of
each subsequent page.
SECTIONS 1 THROUGH SECTION 11 MUST BE COMPLETED BY A LICENSED/CERTIFIED MEDICAL
PROFESSIONAL.
NOTE: A licensed/certified medical professional means an occupational or physical therapist, a physiatrist or
rehabilitation...
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