Get Ohio Medicaid Application

Filling out the Ohio Medicaid Application can seem daunting, but with the right guidance, the process can be straightforward and efficient. This user-friendly guide will walk you through each section of the application, ensuring that you understand the requirements and can complete it accurately.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering consumer information. Fill out the consumer's name, street address, city, phone number, state, zip code, and county of residence. Ensure that the Medicaid number and date of birth are entered accurately. If applicable, include the name and phone number of the parent or guardian.
3. Indicate the waiver type by checking the appropriate box. Choose between ODA-Administered Waiver, DODD-Administered Waiver, or No Waiver as applicable.
4. Provide authorization information by confirming that you are requesting private duty nursing services and that you authorize the case manager or provider to submit this request and exchange relevant protected health information.
5. Complete the provider information section with the provider’s name, street address, phone number, fax number, Ohio Medicaid provider number, email address, national provider identifier number, and nursing license number.
6. Ensure that the individual submitting the form certifies the truthfulness of the information provided. This statement is crucial for compliance with federal and state laws.
7. If applicable, complete the ODA or DODD case manager information section. Include their name, phone number, fax number, and email address.
8. If you are requesting PDN services beyond the 60-day post-hospital state plan benefit, provide details as required, including physician substantiation.
9. Submit any relevant notifications for emergency services or changes in services if applicable, with complete details as requested.
10. Finally, review all entries for accuracy, save your changes, and prepare to submit the application as directed, either online or through the appropriate channels.

Complete your Ohio Medicaid Application online today to ensure timely processing and eligibility verification.