Adoption Medical Subsidy
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Complete Prior Approval Request Form
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Written statement requesting the service; signed by guardian (Example Below)
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Send to Adoption Subsidy Caseworker (Find them on the AGAO Staff Contact List)
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After approval; submit claims to: MDHHS-MedicalSubsidyClaims@michigan.gov
Find out more here: https://www.michigan.gov/mdhhs/adult-child-serv/adoption/post-adoption-resources/post-adopt-assist
[Date]
As the caregivers for [Child's Name(s)], we are formally requesting respite services. These services are crucial for us to take necessary breaks and recharge, ensuring that we can continue to provide the best care while knowing they are in a safe and supportive environment. This support is vital for the well-being of our entire family.
[Caregiver Name]
[Caregiver Signature]