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Get Michigan Evaluation 2018-2024

Care Organizations Act, MCL 722.11, this form is confidential and shall not be released. DIRECTIONS FOR COMPLETING FORM: Please read the reverse side before completing this form. Please type or print so that the information completed can be read. Email the completed form to the DCWL 259 mailbox at MDHHS-DCWL-259 michigan.gov. All MDHHS and PAFC CPA s must complete the Non-CPS Intake CWL-259 in MiSACWIS and submit the completed form to the DCWL 259 email box. SECTION I: DEPART.

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