Get Ohio Access Success Project Application - Ohio Department Of

This guide provides a step-by-step approach to successfully completing the Ohio Access Success Project Application online. Whether you are familiar with online forms or new to the process, this comprehensive resource will support you in accurately filling out the application.

Follow the steps to complete your application with ease.

1. Click ‘Get Form’ button to access the Ohio Access Success Project Application and open it in your preferred editing tool.
2. Begin by entering the applicant’s full name in the designated fields, ensuring you provide the last name, first name, and middle initial.
3. Indicate whether the applicant is currently enrolled in Medicaid by selecting yes or no.
4. Select the applicant's gender by marking the appropriate box.
5. Input the name of the facility where the applicant will be receiving services, if applicable.
6. Provide the 12-digit Medicaid billing number, if the applicant is enrolled in Medicaid.
7. Fill in the applicant's date of birth in the specified MM/DD/YYYY format.
8. Indicate the preferred language of the applicant.
9. Select the county where the applicant resides.
10. Input the date of admission in the required format.
11. Complete the street address, city, state, and zip code of the applicant’s residence.
12. Provide the facility's phone number and fax number.
13. Identify the referral source by selecting from the list provided, including options like nursing facility, self, hospital, etc., and specify any other source if needed.
14. Fill in the name of the person or agency making the referral and their contact information.
15. If applicable, complete the section for legal guardian or authorized representative, including their contact information and type of guardianship.
16. If the applicant is under 18, include the name and contact information of the parent.
17. Provide contact information for any other individuals who may be contacted regarding the applicant.
18. Ensure the applicant, legal guardian, or authorized representative signs and dates the application at the designated area.
19. Once the form is complete, you can save your changes, download the document, print it, or share it as needed.

Complete your application online today to ensure timely processing of the Ohio Access Success Project.