Get Oh Oda-1105 2008-2026

The OH ODA-1105 form is an essential application for certification as a long-term care agency or service provider in Ohio. This guide will provide you with detailed, step-by-step instructions to successfully complete the form online, ensuring all necessary information is accurately captured.

Follow the steps to complete the OH ODA-1105 online.

1. Click ‘Get Form’ button to access the OH ODA-1105 form and open it in the online editor.
2. Begin by filling in the identifying information section. Include the legal name of the applicant and any 'Doing Business As' (dba) name, if applicable. Input the social security number for individuals or the federal tax ID number for partnerships and corporations.
3. Provide the business address and separate mailing/billing address if different. Please note that a post office box is not permitted for these sections.
4. Complete the contact information, including phone numbers, toll-free numbers, fax numbers, and email address.
5. Answer the questions regarding prior Ohio Medicaid Provider Numbers and Medicare certification status by selecting 'Yes' or 'No' as applicable.
6. Indicate the ownership structure by selecting the appropriate category and filling in details regarding the applicant's legal structure.
7. Fill in the key personnel section with the full name and address of the CEO and the agency administrator, if different. Include contact information for key roles involved in service orders and application signing.
8. Detail how bills will be submitted by selecting the appropriate method such as paper, CD Rom, or direct data entry.
9. Provide the type of certification the agency seeks and include any relevant agency license numbers. Report any changes in ownership and key personnel within the past year and any expected changes within the coming year.
10. Answer questions regarding criminal convictions associated with directors or officers and indicate if the applicant is operated by a management company.
11. Record important dates, including the establishment date in Ohio and the date of services commencement.
12. Indicate whether there is an employee drug testing policy in place.
13. Ensure to attach required documentation as specified in the application, including ownership statements and insurance certificates.
14. Once all sections of the form are filled out completely, you can save your changes, download the document, print it, or share it as necessary.

Complete the OH ODA-1105 online today to ensure your long-term care agency is certified effectively.