Get Personal Needs Allowance (pna) Account Remittance Notice

Filling out the Personal Needs Allowance Account Remittance Notice is a crucial process in managing the finances of deceased residents under Ohio's Medicaid program. This guide will walk you through each section of the form, ensuring you have the necessary information to complete it accurately online.

Follow the steps to complete this important form.

1. Click ‘Get Form’ button to obtain the form and access it in your preferred online editor.
2. In Section A, enter the following resident information: Last name, first name, social security number, Medicaid billing number (12 digits), check or money order number, middle initial, date of death (formatted as mm/dd/yyyy), and the remittance amount. Make sure the information is correct to avoid processing delays.
3. Proceed to Section B to fill in the details of the deceased person's responsible party or next of kin. Provide the last name, first name, middle initial, relationship to the deceased, street address, city, state, and any other relevant contact information.
4. In Section C, include the facility information by providing the Medicaid provider number (7 digits), zip code, phone number, contact name, facility name, street address, city, state, zip code, and another phone number if applicable.
5. Ensure the form has been signed by a provider representative to validate the submission. Review all sections for completeness and accuracy.
6. Once completed, take a moment to review the entire form for any errors. After confirming the accuracy, save the changes and prepare to send the form.
7. Finally, mail this form along with the remittance to the specified address: Attorney General’s Office, Collections Enforcement, Medicaid Estate Recovery, 150 East Gay Street, 21st Floor, Columbus, Ohio 43215.

Start completing your PERSONAL NEEDS ALLOWANCE (PNA) ACCOUNT REMITTANCE NOTICE online to ensure prompt processing.