Get Odm 09405 Form

Filling out the Odm 09405 Form online is a straightforward process designed to assist you in submitting information regarding the Personal Needs Allowance account for a deceased resident. This guide will provide clear and detailed instructions to ensure successful completion of the form.

Follow the steps to fill out the Odm 09405 Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In section A, enter the deceased resident's full name, including first, middle initial, and last name. Provide the social security number and the 12-digit Medicaid billing number.
3. Fill in the check or money order number and the date of death. Specify the remittance amount in the designated field.
4. Proceed to section B, where you will provide the name of the deceased person's responsible party or next of kin. Specify their relationship to the deceased and complete their address, including city, state, zip code, and phone number.
5. In section C, enter the 7-digit Medicaid provider number, contact name, facility name, and the complete facility address. Include the facility's city, state, zip code, and phone number.
6. Ensure the signature of the provider representative is affixed in the appropriate space.
7. Once all sections are filled in accurately, save your changes. You can then download, print, or share the form as required.

Complete your Odm 09405 Form online today to ensure timely processing of the necessary information.