Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing Section A of the form. Enter the individual's full name, Social Security Number, and contact information including phone number, address, city, state, and zip code. Make sure to print clearly.
3. If applicable, provide the name and address of the representative payee or legal guardian, along with their phone number.
4. Move to Section B, which must be completed by the County Department of Job and Family Services (CDJFS). Answer whether the individual is currently on Medicaid by selecting 'Yes' or 'No' and include any spenddown amount if applicable.
5. Authorize the Ohio Department of Mental Health and the CDJFS to exchange necessary information regarding eligibility for Medicaid and the RSS Program by signing at the bottom of Section B.
6. In Section C, the individual in need of RSS, or their representative payee/guardian if applicable, should provide their signature and the date.
7. After completing all sections of the form, you will have the option to save changes, download, print, or share the completed form.

Complete your documents online with confidence and ensure your eligibility today!