Get Odm 09401 Form

The Odm 09401 Form is essential for reporting admissions and discharges of nursing facility residents. This guide will walk you through each section of the form, ensuring that you understand how to complete it accurately and efficiently online.

Follow the steps to fill out the Odm 09401 Form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the resident information. Fill in the 'First Name'*, 'Last Name'*, 'Medicaid Number', 'Social Security Number'*, 'Middle Initial', and 'Date of Birth' (mm/dd/yyyy). Ensure that you complete all required fields marked with an asterisk (*). If the individual does not have a Medicaid Number, indicate whether a Medicaid application has been submitted by selecting the appropriate option and providing the application date if applicable.
3. Navigate to the facility information section for admission or nursing facility transfer. Input the 'Admission Date' (mm/dd/yyyy)* and select the 'Type of Admission*. Check the appropriate box for 'Fee-For-Service', 'Managed Care', or 'New Medicaid Applicant'. Also, include the 'Plan Name' and any additional comments as needed.
4. Proceed to the facility information section regarding discharge, death, or nursing facility transfer. Enter 'Date of Discharge'* (mm/dd/yyyy) and select the 'Reason for Discharge*' from the options provided. This includes 'Waiver Enrollment', 'Assisted Living Waiver Enrollment', 'NF to NF Transfer', 'Home/Community', 'Death', or 'Other'. If applicable, provide the date of death.
5. Complete the submitter information by providing your 'Submitter Name*' (First and Last), 'Facility Name*', 'Medicaid Provider Number*' (7-9 digits), 'Email Address*', and 'Telephone Number*'. Finally, enter the 'Date*' (mm/dd/yyyy) at the bottom of the form.
6. Review all the information entered for accuracy and completeness. Once confirmed, you can save changes, download a copy, print the form, or share it as required.

Start filling out your Odm 09401 Form online today to ensure timely reporting.