Get Ohio Jfs 2399 Form

Filling out the Ohio Jfs 2399 Form online is a straightforward process designed to facilitate your request for Medicaid Home and Community-Based Services. This guide provides detailed, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete and submit the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing Section I, which requires information about the individual or HCBS referring agency. Start with the name, social security number, and address. Be sure to print clearly.
3. Fill in the date of birth, phone number, and the name and contact details of any authorized representative if applicable.
4. Indicate which waiver you are applying for by checking all relevant options, including any specified waivers under the Ohio Department of Job and Family Services, Medicaid, or other listed categories.
5. Provide your signature and date in the designated area to authorize the County Department of Job and Family Services to explore your eligibility for Medicaid coverage.
6. List the name of the person who assisted you in completing this form, including their signature and date.
7. In Section II, leave the area for the CDJFS to complete, which includes the name and signature of the case worker, and the date received.
8. Ensure that all information is accurate and complete, then save your changes, download a copy of the form, print it if necessary, or share it as required.

Complete your documents online today to ensure a smooth application process.