Get Oh Dmhas-7097 2014-2026

The OH DMHAS-7097 form is essential for individuals seeking financial assistance related to mental health and addiction services in Ohio. This guide will help you understand each section of the form and provide clear instructions on how to complete it online.

Follow the steps to successfully complete the OH DMHAS-7097 form online.

1. Press the ‘Get Form’ button to access the OH DMHAS-7097 form and open it in your online document editor.
2. Begin by entering the patient's basic information, including their name, hospital, Social Security number, admission date, marital status, and date of birth.
3. Provide the patient's address, including city, state, and zip code. If the patient is married, include the spouse's information, such as their name, date of birth, and Social Security number.
4. Indicate if the patient is a veteran by selecting 'Yes' or 'No' and, if applicable, provide their VA claim number.
5. Complete the section regarding guardianship, specifying if the patient has a court-appointed guardian and their contact information.
6. Fill out the insurance information, indicating whether the patient has private or public insurance, including Medicare and Medicaid details.
7. Report on the patient’s employment status, income, and any additional sources of income, including information about their spouse.
8. List all bank accounts owned by the patient or spouse, detailing the account type and current balance.
9. Provide information about any real estate owned, including the market value and current mortgage balance.
10. Detail any liabilities and monthly expenses, identifying the relevant amounts for each.
11. Answer questions regarding life insurance and any prepaid funeral expenses, filling in all necessary details.
12. At the end of the form, certify that the information provided is accurate by signing and dating the application. Once completed, users can save changes, download, print, or share the form.

Complete your OH DMHAS-7097 form online today to ensure your application for financial assistance is accurately submitted.