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  • Odm Form 9401

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CLEAR FORMOhio Department of MedicaidPregnancy Risk Assessment Communication (PRAF)DO NOT USE the Care Connection form for Medicaid patients Date of Service (mm/dd/yyyy)Practice Name Practice.

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*If you need to change or update your name, please note that you will need to contact your local JFS office or utilize the Ohio Benefits Self-Service Portal. You will not be able to change or update your name by contacting the Ohio Medicaid Consumer Hotline.

You can generate and print a temporary Medicaid card from Ohio SACWIS, for example, if the child needs a prescription filled quickly. Generate a temporary Medicaid card as follows: Click the Financial tab at the top of the screen. Click the Eligibility tab.

Advanced Imaging Prior Authorization Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures: MRI/MRAs. CT/CTA scans.

Read the application carefully. Attach copies of your proof of income, resources (such as cash, savings, checking, real property, stocks, bonds, etc.), proof of citizenship or alien status, pregnancy if applicable, and other insurance you may have.

To be eligible for coverage, you must: Be a United States citizen or meet Medicaid citizenship requirements. Your local county Job and Family Services office can help to explain these requirements and can help get you enrolled. Have or get a Social Security number. Be an Ohio resident. Meet financial requirements.

If you're a provider, call our Provider Hotline at 800-686-1516. If you're an Ohio Medicaid member, call our Consumer Hotline at 800-324-8680.

All in-patient services require prior authorization. Please call 1-800-488-0134Navigate to tel:1-833-230-2101Navigate to tel:1-833-230-2101Navigate to tel:1-833-230-2101 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.

If you're a provider, call our Provider Hotline at 800-686-1516. If you're an Ohio Medicaid member, call our Consumer Hotline at 800-324-8680.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232