DHS-390, MDHHS-6200 and MSA-4676 Forms for Michigan Home Help Program
What Are These Forms and Why Are They Important?
If you're applying to get paid as a caregiver through Michigan Medicaid, you'll need to complete specific paperwork, often called CHAMPS caregiver forms or Medicaid caregiver documents. These forms are required by the Michigan Home Help Program to approve you or your loved one for paid caregiving services.
Below you will find the necessary forms required for applying to the Michigan Home Help Program. Click on the links to view or download the forms, and read the descriptions to understand their purpose. If you have any questions, please feel free to contact us.
Adult Services Application (DHS-390)
This form starts the application process for the Michigan Home Help Program. It must be filled out by the applicant or their legal guardian and submitted to MDHHS.
Home Help Services Agreement (MSA-4676)
Formally selects CarePlan Inc. as your designated home care provider so we can handle your state billing, guide you through the process, and issue your payments and onboarding bonus. (Signed by the applicant and CarePlan Inc).
Adult Services Medical Needs Certification (MDHHS-6200)
This form certifies the need for personal care services for the Michigan Home Help Program. MDHHS is transitioning to MDHHS-6200 as the primary medical needs certification form, replacing DHS-54A. It must be completed by an approved Medicaid-enrolled medical provider.
Common Questions:
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This form names the caregiver. It's part of the “get paid to care” application and is required by the state. Anyone applying to be a caregiver must submit it . Whether they’re a family member, friend, or roommate.
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The MDHHS-6200 (Adult Services Medical Needs Certification) is a medical form completed by an approved medical provider. It certifies that the care recipient needs help with daily activities such as bathing, dressing, cooking, or mobility in order to qualify for the Michigan Home Help Program.
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The MDHHS-6200 must be completed and signed by an approved, Medicaid-enrolled medical provider, such as a physician, nurse practitioner, physician assistant, or licensed therapist.
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These forms are typically submitted:
When applying for Michigan Home Help services
During renewals
When there is a change in medical condition or care needs
Submitting complete and accurate forms helps avoid delays in processing.
Need Help Completing These Forms?
We help families every day with the forms and approval process.
Questions? We're Here to Help
If you're confused or unsure about which forms to use or how to submit them, our team can help answer your questions.
👉 Contact us or check your eligibility now to get started.